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SURGICAL OBSERVATIONS 



DISEASES OF THE JOINTS. 



PATHOLOGICAL 



AND 



SURGICAL OBSERVATIONS 



DISEASES OF THE JOINTS. 



SIR BENJAMIN C: BRODIE, BART., F. R. S. 

SERGEANT'SURGEON TO THE KING, SURGEON TO ST. GEORGE'S HOSPITAL, AND AUTHOR OF 
DISEASES OF THE URINARY ORGANS, &C. 



FROM THE FOURTH LONDON EDITION, WITH THE AUTHOR'S 
ALTERATIONS AND ADDITIONS. 



PHILADELPHIA: 
LEA AND BLANCHARD. 

1843. 



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•Wm, S. Young, Printer. 






PREFACE 



TO THE 

F OURTH EDITION 



Since this treatise was first offered to the public, I 
have had considerable opportunities of obtaining in- 
formation on the subjects to which it relates, and of 
these I have endeavoured to avail myself, as far as it 
was in my power to do so, amid the interruptions oc- 
casioned by the various other pursuits in which I have 
been engaged. I have thus been enabled, in the lat- 
ter editions, to describe several forms of disease, with 
which I was formerly unacquainted; to give a more 
complete and exact history of the symptoms by which 
the different diseases of the joints are indicated in the 
living person; and to suggest (as I hope) more efficient 
modes of practice with a view to their relief or cure. 
If I am not much mistaken, it is in this last respect 
that the observations contained in the present volume 
will be found to differ most from those which were 
the result of my earlier investigations. As I have be- 
come more versed in the practical duties of my pro- 
fession, so I have become more convinced that local 
diseases, in the strict sense of the term, are of compa- 
ratively rare occurrence; and that those, which are 
usually regarded as being of this description, may, for 
the most part, be traced to a morbid condition of the 
general system. The local treatment of the diseases 
of the joints, which I now recommend, is even more 
simple than that which I recommended formerly; but 
it is quite otherwise with respect to those remedies, 



VI PREFACE. 



which operate through the medium of the constitution. 
Experience has not only confirmed me in the opinion 
that remedies of this class may often be employed with 
great advantage to the patient, but has also taught me 
that there are few cases, in which a cure can be easily 
obtained without them. 

There are some points connected with the pathology 
of the joints, respecting which others, whose knowledge 
and discernment I cannot too highly estimate, have 
been led to form opinions different from those which I 
had myself adopted, and which I still believe to be 
correct; and on one of these I have ventured to offer 
some remarks in a note at the end of this volume. 
Nothing, however, can be farther from my intention 
than to enter into any controversial discussion on these 
subjects. I have endeavoured, accurately and faith- 
fully to record the facts, which have fallen under my 
observation; and, in the advancement of knowledge, 
time cannot fail to show how far the conclusions, at 
which I have arrived, are well founded. I trust that 
I have sufficient love of science to lead me to desire 
nothing so much as the attainment of truth; and that 
I am not so vain as to believe that none of my views 
can be erroneous. Indeed, one principal result of my 
labours has been to convince me that life is not long 
enough for these difficult researches; that the utmost 
which can be accomplished by the zeal and industry 
of an individual is to make such progress in the study 
of pathology as may enable those who come after him 
to carry their inquiries farther; and that the expecta- 
tions of any one who aims at higher objects than these 
must terminate in disappointment. 



CONTENTS. 



Introduction, ix 

CHAPTER I. 

ON INFLAMMATION OF THE SYNOVIAL MEMBRANES %F JOINTS. 

Sect. I. Pathological Observations, 11 

Sect. II. On the Causes and Symptoms of this disease, - - 18 

Sect. III. On the Treatment, - - - - v - - - 25 

Sect. IV. Cases, - 34 

CHAPTER II. 

ON ULCERATION OF THE SYNOVIAL MEMBRANE, - - - - 49 

CHAPTER III. 

ON CASES IN WHICH THE SYNOVIAL MEMBRANE HAS UNDERGONE A 
MORBID CHANGE OF STRUCTURE. 

Sect. I. Pathological Observations, - - - - - - 50 

Sect. II. On the Symptoms of this Disease, - - - - 60 

Sect. III. On the Treatment, - - - - - - -62 

CHAPTER IV. 

ON THE ULCERATION OF THE ARTICULAR CARTILAGES. 

Sect. I. Pathological Observations, - 63 

Sect. II. On the Symptoms of this Disease, - - - - 83 

Sect. III. On the Treatment, - 93 

Sect. IV. Cases, - 108 

CHAPTER V. 

ON A SCROFULOUS DISEASE OF THE JOINTS, HAVING ITS ORIGIN IN THE 
CANCELLOUS STRUCTURE OF THE BONES. 

Sect. I. Pathological Observations, 118 

Sect. II. On the Symptoms of this Disease, - - - -126 

Sect. III. On the Treatment, - 131 

Sect. IV. Cases, - - * - 138 



Vlll CONTENTS. 

CHAPTER VI. 

ON CARIES OF THE SPINE. 

Sect. I. Pathological Observations, 147 

Sect. II. On the Symptoms of Caries of the Spine, - 157 

Sect. III. On the Treatment, - - - . . . . 167 

CHAPTER VII. 

ON TUMOURS AND LOOSE CARTILAGES IN THE CAVITIES OF THE 

JOINTS, 171 

CHAPTER VIII. 

ON MALIGNANT DISEASES OF THE JOINTS, - 176 

CHAPTER IX. 

ON SOME OTHER DISEASES OF THE JOINTS, - - -.,'"','- - 182 

CHAPTER X. 

ON INFLAMMATION OF THE BURS^J MUCOSJE. 

Sect. I. History and Symptoms of this Disease, - 200 

Sect. II. On the Treatment, - . . . . . .203 

Sect. III. Cases, 205 

NOTE. 
On Ulceration of the Articular Cartilages, 208 



INTRODUCTION. 



The following pages contain a series of observations, which 
were begun several years ago, and which have been continued, 
not without considerable labour, up to the present period. 
They relate to a class of diseases which have strong claims on 
the attention of the surgeon; since they are of very frequent 
occurrence; are a source of serious anxiety to the patients; and, 
for the most part, if neglected, proceed to an unfavourable ter- 
mination. There are other circumstances, also, which seem to 
render the morbid affections of the joints a fit subject of inves- 
tigation. They have scarcely met with the attention which 
they merit from former pathologists. The terms, white swell- 
ings, scrofulous joints, &c, have been used without any well- 
defined meaning, and almost indiscriminately; so that the same 
name has been frequently applied to different diseases, and the 
same disease has been distinguished by different appellations. 
Confusion with respect to diagnosis always gives rise to a cor- 
responding confusion with respect to the employment of reme- 
dies; and hence I was induced to hope, that, if it were possible 
to improve our pathological knowledge of the diseases to which 
I have alluded, this might lead, not indeed to the discovery of 
new methods of treatment, but to a more judicious and scientific 
application of those which are already known, and a consequent 
improvement of chirurgical practice. 

The joints,like the other animal organs,are not of a simple and 
uniform, but of a various and complicated structure. Although, 
in the advanced stages, the diseases to which they are liable 
extend to all the dissimilar parts of which they are composed, 
it is to be presumed that such is not the case in the beginning. 
We cannot doubt that here, as elsewhere, the morbid actions 
commence sometimes in one, and sometimes in another texture; 
2 



X INTRODUCTION. 

and that they differ in their nature, and are variously modified, 
and, of course, require to be differently treated, according to the 
mechanical organization, and the vital properties of the part 
in which they originate. 

It was under the influence of these impressions that I endea- 
voured to pursue my inquiries into the subject of the present 
treatise. Believing that nothing has contributed in a greater 
degree towards the modern improvements in surgery, than the 
practice of investigating by dissection the changes of anatomical 
structure which disease produces, I availed myself of every op- 
portunity which occurred of making such examinations. In 
particular, I was anxious to do this where the morbid changes 
were still in an early stage, and where I had the opportunity of 
noting the symptoms by which the incipient disease was indi- 
cated; and the knowledge which was thus acquired became the 
basis of my future observations. In laying the results before 
the public, I cannot be otherwise than conscious, that these re- 
searches are still imperfect. But I feel assured, at the same 
time, that those who are engaged in the study of pathology, will 
make due allowance for the difficulties which belong to this most 
complicated of all the sciences, and will not be disposed to criti- 
cise my labours severely, because they find that there is still an 
ample space left for those who may be willing to engage in 
similar inquiries. 

Some of my readers will recognise in the present work the 
substance of three papers, which have been published in the 
fourth and two subsequent volumes of the Medico-Chirurgical 
Transactions; but they will also find a considerable proportion 
of new matter. I have met with no reasons for altering my 
former arrangement of those affections of the joints which are 
of most frequent occurrence. Indeed, it has been to me a source 
of much satisfaction,that all my subsequent observations,founded 
on numerous additional cases and dissections, have tended to 
confirm the accuracy of those pathological views which I was 
led to adopt several years ago, and which I ventured to bring 
forward in the first of those papers to which I have alluded. 



CHAPTER L 



ON INFLAMMATION OF THE SYNOVIAL MEMBRANES OF 

JOINTS. 



SECTION I. 



PATHOLOGICAL OBSERVATIONS. 

The soft parts, which, added to the bones and cartilages, 
constitute the structure of the joints, are, the synovial mem- 
branes, by which the lubricating fluid is secreted; the liga- 
ments, by which the bones are connected to each other; and 
the fatty substance, which occupies what in certain positions 
would otherwise be empty spaces. It is to be supposed, that 
the adipose membrane belonging to the joints may be inflamed; 
that it may be the seat of abscesses and tumours, as well as 
that which is situated beneath the' skin or in the interstices of 
the muscles; and the ligaments cannot be regarded as more 
exempt from disease than the fibrous membranes, which they 
very nearly resemble in their texture. It is not improbable 
that some of the pains which take place in the joints in syphi- 
litic affections, may depend on a diseased action occurring in 
the ligaments; and there can be no doubt that the long con- 
tinued symptoms, which occasionally follow a severe sprain, 
depend on these same parts being in a state of slow inflamma- 
tion, in consequence of some of their fibres having been rup- 
tured, or over-stretched. I cannot say that I have never seen 
a case where disease, independently of these causes, has ori- 
ginated in the ligaments; but I certainly have never met with 
a case where it has been proved to have done so by dissection; 



12 ON INFLAMMATION OP THE 

and it may be safely asserted, that this is a rare occurrence, 
and not what happens in the ordinary diseases to which the 
joints are liable. 

On the other hand, no part of the body is much more fre- 
quently diseased than the synovial membranes. This is what 
their anatomical structure and functions might lead us to ex- 
pect, since we find that living organs are more subject to have 
their natural functions deranged, in proportion as they are more 
vascular, and as they are employed in a greater degree in the 
process of secretion. 

The synovial membranes of the joints have not been well 
described by the majority of the old, nor even of modern 
anatomists. A sufficiently accurate account of them, however, 
has been published by Dr. W. Hunter, in a communication to 
the Royal Society, on the structure of cartilage, published in 
the forty-second volume of the Philosophical Transactions, and 
since then by M. Bichat, in his Traite des Membranes; and to 
these authors 1 may refer those of my readers who wish to see 
their anatomy more fully explained. At present it is sufficient 
for me to observe, that the office of the synovial membrane of 
a joint is to secrete the synovia, by which the joint is lubricated; 
that it lines the ligaments, by which the bones are held together; 
covers the bones themselves for a small extent, taking the place 
of the periosteum; and that from thence it passes over the car- 
tilaginous surfaces, and the interarticular fat. Where it adheres 
to the bones and soft parts, it very much resembles the perito- 
naeum in its structure, and possesses considerable vascularity; 
hut where it is reflected over the cartilages it is thin, and readily 
torn : its existence, however, even here, may be always distinctly 
demonstrated by a careful dissection. The synovial membrane 
of a joint forms a bag, having no external opening; in this re- 
spect resembling the peritonaeum, the pleura, and the pericar- 
dium: which it also resembles in its functions, and to which it 
bears some analogy in its diseases. 

Cases occasionally (but not often) occur, in which a joint is 
swollen from a preternatural quantity of fluid collected in its 
cavity, without pain or inflammation. This may be supposed 
to arise, either from a diminished action of the absorbents, or 
an increased action of the secreting vessels. The disease may be 
compared to the dropsy of the peritonaeum or pleura; or, more 



SYNOVIAL MEMBRANES OF JOINTS. 13 

properly, to the hydrocele; and it has been not improperly de- 
signated by the terms " Hydarthrus" and "Hydrops articuli." 

It more frequently happens that there is swelling from fluid 
in a joint, with inflammation and pain. Here we may presume 
that the disease consists in an inflammation of the synovial mem- 
brane, with a consequent increase of the secretion from its sur- 
face; and I have found this opinion to be confirmed by the ap- 
pearances observed in many such cases, in which 1 had the op- 
portunity of examining the affected parts after death. 

In some instances, while there is still pain and inflammation 
in the joint, the fluid is felt indistinctly, as if a considerable 
mass of soft substance lay over it. Often, when the inflamma- 
tion has subsided, and the fluid is no longer to be felt, the joint 
remains swollen and stiff; painful, when bent or extended be- 
yond a certain point, and liable to a return of inflammation from 
slight causes. The appearances observed on dissection, in the 
following cases, seem to throw light on this subject. 

CASE 1. 

A middle-aged man was admitted into St. George's Hospital 
in September, 1810, on account of a disease in one knee. The 
joint was swollen and painful, with slight stiffness, and with 
fluid in its cavity. The swelling extended some way up the 
anterior part of the thigh, behind the lower portion of the ex- 
tensor muscles. It subsided under the use of blisters and lini- 
ments. Two months after his admission into the hospital, Ke 
was seized with a fever, apparently unconnected with the dis- 
ease in the knee, of which he died. On examining the affected 
joint, the synovial membrane was found more capacious than 
natural, so* that it extended up the anterior surface of the femur 
at least an inch and a half higher than under ordinary circum- 
stances. Throughout the whole of its internal surface, except 
where it covered the cartilages, the membrane was of a dark- 
red colour; the vessels being as numerous and as much distended 
with blood, as those of the tunica conjunctiva of the eye in a 
violent ophthalmia. At the upper and anterior part of the 
joint, a thin flake of coagulated lymph of the size of a half-crown 
piece was found adhering to the inner surface of the synovial 
membrane. There was no other appearance of disease, except 
that at the edge of one of the condyles of the femur the car- 
tilage adhered to the bone less firmly than usual. 

2* 



14 ON INFLAMMATION OP THE 

CASE II. 

A. B., a young man, in the spring of the year 1808, in con- 
sequence (as he supposed) of exposure to damp and cold, became 
affected with a painful swelling of one of his knees. Under the 
treatment employed by the practitioner w 7 hom he consulted, 
the pain and swelling in great measure, but not entirely,subsided. 
Three months after the disease first took place, he was admitted 
into St. George's Hospital. At this time the knee was swollen, 
painful, and tender. The swelling had the form of the articu- 
lating ends of the bones. The leg was confined to nearly the 
straight position, and admitted of very little motion on the 
thigh. His general health was unaffected. 

Blood was taken from the knee by cupping; and afterwards 
it was rubbed daily with mercurial ointment and camphor. The 
pain and inflammation subsided; and the swelling and stiffness 
were in some measure lessened. It afterwards became necessary 
to amputate the limb on account of another disease. The ope- 
ration was performed on the 15th of December, 1808, and I 
did not neglect the opportunity of examining the joint. 

The bones, cartilages, and ligaments were in a natural state. 
The synovial membrane was increased in thickness to about 
one-eighth of an inch, and was of a gristly texture. It was 
closely attached to the surrounding cellular membrane and fascia 
by means of coagulated lymph, which had been formerly ef- 
fused on its external surface. 

CASE HI. 

A middle-aged man, w T ho laboured under an organic disease 
of the liver, was admitted into St. George's Hospital on the 
19th of December, 1821, on account of a painful swelling of 
one knee. Blood was taken from the knee by cupping, and af- 
terwards blisters were applied. The affection of the knee was 
much relieved under this treatment, but the joint remained 
rather larger than natural, and somewhat stiff. The disease in 
the liver continued to make progress, and the man died on 
the 11th of February, 1822. On examining the body after 
death, the synovial membrane of the knee was found slightly 
thickened, and of a gristly structure. The vessels on its inner 
surface were more loaded with blood than under ordinary cir- 
cumstances. The cartilage covering that portion of the articu- 



SYNOVIAL MEMBRANES OF JOINTS. 15 

lating extremity of the femur which corresponds to the pa- 
tella, in one spot of about three quarters of an inch in dia- 
meter, presented an irregular surface, as if it had been partially 
absorbed, but not to a sufficient extent to expose the surface 
of the bone below. 



These cases seem to explain the usual consequences of in- 
flammation of the synovial membrane. It occasions, 1st, a 
preternatural secretion of synovia; 2dly, effusion of coagulated 
lymph into the cavity of the joint; 3dly, in other cases, a thick- 
ening of the membrane; a conversion of it into a gristly sub- 
stance; and an effusion of coagulated lymph, and probably of 
serum, into the cellular texture by which it is connected to the 
external parts. 

I have seen several cases where, from the appearance of the 
joint, and other circumstances, there was every reason to be- 
lieve that the inflammation had produced adhesions, more or 
less extensive, of the reflected folds of the membrane to each 
other; and 1 have observed occasionally, in dissection, such par- 
tial adhesions as might reasonably be supposed to have arisen 
from inflammation at some former period. 

The slight adhesion of the cartilage to the bone, in the first 
of the cases, which have been related, and the partial absorp- 
tion of the cartilage in the last case, we must suppose to have 
been the consequence of the greater disease in the synovial 
membrane. In another case, in which the patient, having re- 
covered of inflammation of the synovial membrane, died seve- 
ral months afterwards of another disease, I found, on dissection, 
that the greater part of the cartilage of the patella, and a small 
portion of that covering the condyles of the femur, had dis- 
appeared, and that its place was occupied by a thin yellow mem- 
branous substance adhering to the bone, and forming a distinct 
cicatrix. I have known many cases in which there was exten- 
sive destruction of the cartilages of a joint by ulceration, mani- 
festly arising from neglected inflammation of the synovial mem- 
brane. That this should happen is no more remarkable than 
that ulcer of the cornea should occasionally be induced by in- 
flammation of the tunica conjunctiva of the eye. This termination 
of the disease is not uncommcm in the labouring classes of society, 
who frequently do not obtain proper surgical assistance during 



16 ON INFLAMMATION OF THE 

the existence of the earlier symptoms. Among others it is com- 
paratively rare; and on the whole I believe that it will be found 
in the majority of cases of caries of the joints, that the disease 
has begun in the harder textures. 

Inflammation of the synovial membrane occasionally termi- 
nates in suppuration, without having induced ulceration of either 
the soft or hard textures of the joints. I found this to have 
happened in the case of a patient who died in consequence of 
a small wound, which had penetrated into the elbow, the joint 
being full of pus, although there was no ulcerated surface. The 
same thing occasionally occurs where the inflammation has not 
had its origin in a mechanical injury; but the fact can be ascer- 
tained only where an opportunity occurs of examining the parts 
immediately after" suppuration is established, as ulceration of the 
cartilages soon follows the formation of an abscess under such 
circumstances, in an articular cavity. 

There is a peculiar morbid state of the system, which, in 
some instances, follows severe accidents, or operations, and 
which is well known to surgeons who are ergaged in the prac- 
tice of the London Hospitals, in which the patients are liable to 
deposites of pus in various parts of the body, at a distance from 
the seat of theoriginal injury. These deposites not unfrequently 
take place in the cavities of joints, as a consequence of inflam- 
mation of the synovial membrane, and independently of ulcera- 
tion. Several examples of the kind have fallen under my own 
observation; but it will be sufficient for me to refer to those 
which have been recorded by the late Mr. Rose, and by Mr. 
Arnott, in the fifteenth volume of the Medico-Chirurgical 
Transactions. 

In one of the cases related by Mr. Arnott, it is stated that 
the cavity of the knee-joint was filled with a « tolerably thick 
pus, of a uniformly reddish colour, as if from an admixture 
of blood." The following case affords a still more remarkable 
example of the secretions of an inflamed synovial membrane 
being tinged in the same manner. 

CASE IV. 

Henry Payne, thirty-nine years of age, was admitted into 
St. George's Hospital, under the care of Mr. Hawkins, on the 
7th of October, 1829. 



SYNOVIAL MEMBRANES OF JOINTS. 17 

He had suffered, formerly, from repeated attacks of rheuma- 
tism. 

About twelve weeks ago, after exposure to damp and cold, 
he was seized with inflammation in nearly all his joints. In the 
course of a few days, the disease in the other joints had abated; 
but the right knee became more painful and swollen. At the 
time of his admission, this knee was tender, painful, and much 
distended with fluid, and there was a good deal of febrile ex- 
citement of the system. 

Blood was taken from the neighbourhood of the knee by 
cupping ; and this was followed by the application of blisters. 
The vinum colchici, and afterwards calomel, combined with 
opium, were administered internally. Under this treatment the 
pain and swelling of the knee subsided. 

On the 27th of October, he was attacked with severe inflam- 
mation of the fauces and larynx; which, however, soon yielded 
to the remedies employed. 

On the 31st, he complained of severe pain in the right side, 
with great difficulty of breathing; and on the 3d of November 
he died. 

On examining the body after death, both pleurae were found 
inflamed, and incrusted with lymph, and serum had been effused 
into that of the right side. The lungs, also, were inflamed, 
and some portions of them were in a state of gangrene. The 
heart w T as affected with hypertrophy, and the pericardium was 
inflamed with flakes of lymph adhering to it. The synovial 
membrane of the right knee was full of a dark-coloured fluid; 
not purulent, but having the appearance of a thick synovia, 
tinged with blood. The synovial membrane was every where 
of a red colour, as if stained by this secretion, and the cartilages 
of the joint had the appearance of having been stained in the 
same manner. There were some small extravasations of blood 
in the cellular membrane external to the joint. 



18 ON INFLAMMATION OF THE 



SECTION II. 

ON THE CAUSES AND SYMPTOMS OF THIS DISEASE. 

It is evident that inflammation may affect the synovial 
membrane of a joint, by extending to it from some of the 
other textures of which the joint is composed, or that it may 
have its origin in the membrane itself. My present observa- 
tions are intended to relate chiefly to cases of the latter de- 
scription; and what little is to be said, in addition, respecting 
those of the former, will be better introduced hereafter. 

Although no period of life is altogether exempt from this dis- 
ease, it does not occur equally in persons of all ages. It very 
seldom attacks young children: becomes less rare in those who 
approach the age of puberty; and is very frequent in adult 
persons. This is the reverse of what happens with respect to 
some of the other diseases, to which the joints are liable; and 
a knowledge of these circumstances will be found of some impor- 
tance to the surgeon, in assisting him to form a ready diagnosis. 

Inflammation of the synovial membranes may take place, as 
a symptom of a constitutional affection, where the system is 
under the influence of gout or rheumatism ; where it is disturbed 
by the operation of the syphilitic poison; where mercury has 
been exhibited improperly, or in too large quantities; and un- 
der a variety of other circumstances. But, in these cases, the 
disease, for the most part, is not very severe; it occasions a 
preternatural secretion of synovia; but does not, in general, 
terminate in the effusion of coagulated lymph, or in thick- 
ening of the inflamed membrane. Sometimes it attacks se- 
veral joints at the same instant, and even extends to the sy- 
novial membranes, which constitute the bur,s(z mucosae and 
sheaths of the tendons. At other times it leaves one part to 
attack another, and different joints are affected in succession. 

In other cases, the disease is entirely local; produced by a 
sprain or other injury; or the application of cold; and sometimes 
arising from no evident cause. The application of cold is, on 
the whole, the most frequent source of the complaint; and 






SYNOVIAL MEMBRANES OF JOINTS. 19 

hence it is easy to explain, why it occurs much more fre- 
quently in the knee than in any other joint; and why it is 
comparatively rare in the hip and shoulder, which are defended 
by a thick mass of muscles from the influence of the external 
temperature. Where the inflammation is thus confined to a 
single joint, it is more probable that it will assume a severe 
character, and that it may be of long duration. It is likely to 
leave the joint with its functions more or less impaired; and 
occasionally terminates in its total destruction. In itself it is- 
a serious disease, but it is often confounded, under the alarming 
name of white swelling, with other diseases, which are still 
more serious. 

Inflammation may take place in the synovial membranes in 
different degrees of intensity; but for the most part it has 
the form of a chronic or slow inflammation; which, while it 
impairs, does not altogether destroy, the functions of the joint; 
and which, if not relieved in the first instance, by active and 
judicious treatment, may, like a chronic ophthalmia, continue 
for weeks or months, and, with occasional recoveries and re- 
lapses, may even harass and torment the patient during many 
successive years. 

In the first instance, the patient experiences pain in the joint, 
which, although it affects the whole articulation, is often re- 
ferred principally to one spot, being there felt more severely 
than elsewhere. The pain usually continues to increase during 
the first week or ten days, when it is at its height. Some- 
times even at this period the pain is trifling, so that the patient 
experiences but little inconvenience from it; at other times it 
is considerable, and every motion of the joint is distressing and 
difficult. 

In the course of one or two days after the commencement of 
the pain, the joint may be observed to be swollen. At first, 
the swelling arises entirely from a preternatural collection of 
fluid in its cavity. In the superficial joints, the fluid may 
be distinctly felt to undulate, when pressure is made alter- 
nately by the two hands placed one on each side. When the 
inflammation has existed for some time, the fluid is less percep- 
tible than before, in consequence of the synovial membrane 
having become thickened, or from the effusion of lymph on 
its inner or outer surface; and, in many cases, where the dis- 



20 ON INFLAMMATION OF THE 

ease has been of long standing, although the joint is much 
swollen, and symptoms of inflammation still exist, the fluid in 
its cavity is scarcely to be felt. As the swelling consists more 
of solid substance, so the natural mobility of the joint is in a 
greater degree impaired. 

The form of the swelling deserves notice. It is not that of 
the articulating ends of the bones, and, therefore} it differs from 
the natural form of the joint. The swelling arises chiefly from 
the distended state of the synovial membrane, and hence its 
figure depends in great measure on the situation of the liga- 
ments and tendons, which resist it in certain directions, and 
allow it to take place in others. Thus, when the knee is af- 
fected, the swelling is principally observable on the anterior 
and lower part of the thigh, under the extensor muscles, where 
there is only a yielding cellular structure between these muscles 
and the bone. It is also considerable in the spaces between the 
ligament of the patella and the lateral ligaments; the fluid col- 
lected in the cavity causing the fatty substance to protrude in 
this situation, where the resistance of the external parts is less 
than elsewhere. In the elbow the swelling is principally ob- 
servable in the posterior part of the arm, above the olecranon, 
and under the extensor muscles of the fore-arm; and in the ankle 
it shows itself on each side, in the space between the lateral 
ligaments, and the tendons, which are situated on the anterior 
part. In like manner, in other joints, the figure of the swelling, 
whether it arises from fluid alone, or joined with solid substance, 
depends in great measure on the ligaments and tendons in the 
neighbourhood, and on the degree of resistance which they af- 
ford; and these circumstances, though apparently trifling, de- 
serve our attention, as they enable us more readily to form our 
diagnosis. 

In the hip and shoulder the disease occurs less frequently 
than in the superficial joints: and here the fluctuation of the 
effused fluid is not perceptible; but the existence of swelling is 
sufficiently evident beneath the muscles. 

When the shoulder is affected, there is pain accompanied with 
a general tumefaction of the part; and, in most instances, if the 
hand be placed upon it, at the same time that the limb is 
moved, a crackling sensation is observed, which probably arises 
from an effusion of fluid into the cells of the neighbouring 



SYNOVIAL MEMBRANES OF JOINTS. 21 

bursse. After some time the swelling subsides, or the joint may- 
even appear to be smaller than natural, in consequence of the 
muscles, especially the deltoid, having become waste from want 
of exercise. 

When inflammation attacks the synovial membrane of the 
hip, there is an evident fulness of the groin, and, in some in- 
stances, of the nates also. There is pain, which is referred, not 
to the knee, as in cases of ulceration of the cartilages, but to the 
upper and inner part of the thigh, immediately below the origin 
of the adductor longus muscle. The pain is aggravated when 
the patient stands erect, and allows the limb to hang, without 
the foot resting on the ground. It is also increased by motion, 
but not by pressing the articulating surfaces against each other, 
so that it does not prevent the w r eight of the body being borne 
by the affected limb. The pain is often very severe, yet it does 
not amount to that excruciating sensation which exhausts the 
powers and spirits of the patient in some of the cases in which 
the cartilages of the hip are ulcerated. From some circum- 
stances which have fallen under my observation, I cannot doubt 
that inflammation of the synovial membrane of the hip occa- 
sionally terminates in dislocation of that joint. It is easy to 
understand how this happens, w 7 here the synovial membrane 
and capsular ligament are much distended and dilated, the round 
ligament being at the same time separated from one of its at- 
tachments by ulceration. The head of the femur is pushed out- 
wards until it has passed beyond the bony margin of the aceta- 
bulum, when the action of the glutsei muscles draws it upwards, 
and causes it to be lodged on the dorsum of the ilium. An 
example of this kind of dislocation w 7 ill be found among the 
cases which will be related hereafter. 

After inflammation of the synovial membrane has subsided, 
the fluid is absorbed, and, in some instances, the joint regains 
its natural figure and mobility; but, in other cases, stiffness 
and swelling remain. Sometimes the swelling has the same 
peculiar form, which it possessed while the inflammation still 
existed, and while fluid was contained in the joint; and we may 
then suppose, that it depends principally on the inner surface 
of the synovial membrane having a thick lining of coagulated 
lymph. At other times the swelling has the form of the ar- 
ticulating extremities of the bones, that is, nearly the natural 
3 



22 ON INFLAMMATION OF THE 

form of the joint; and it probably arises from the thickened 
state of the synovial membrane. From whichever of these 
causes it be that a swelling remains after the inflammation has 
subsided, the patient is very liable to a recurrence of the dis- 
ease. Whenever he is exposed to cold, or exercises the limb 
in an unusual degree, and often, without any evident reason, 
the pain returns, and the swelling is augmented. In those 
cases in which the synovial membrane is thickened, although 
the fluid, which had been effused, is absorbed, and the principal 
swelling has disappeared, it occasionally happens, not only that 
a certain degree of inflammation still lingers in the part, but 
that it continues until the morbid action extends to the other 
textures; and ultimately ulceration takes place in the carti- 
lages, suppuration is established, and there is complete destruc- 
tion of the articulating surfaces. In this advanced stage, if we 
w T ish to know whether the inflammation of the synovial mem- 
brane, or the ulceration of the cartilages, has been the primary 
affection, we must form our judgment, not from the present 
symptoms, but from the previous history of the case. It is, 
indeed, often difficult to procure a history on the accuracy of 
which we can rely, particularly in hospital practice; but this 
is of the less importance, as whatever the disease may have 
been in its origin, where it has proceeded so far as has been 
described, there is no difference respecting the treatment; and, 
for the most part, when suppuration has taken place, as the re- 
sult of a chronic disease, and in combination with extensive 
ulceration of the cartilages, there is little prospect of advantage 
from any thing, except the removal of the limb by amputation. 
I believe that the above history will be found applicable to 
the majority of cases in which this disease exists. But I have 
before observed, that inflammation may exist in the synovial 
membranes in different degrees of intensity; and occasionally 
it will be found to be more urgent in its symptoms, and to 
be more rapid in its progress, than what has been described, 
having the characters of an acute instead of a chronic inflam- 
mation. Under these circumstances, the swelling takes place 
immediately after, or at the same instant with, the first attack 
of pain: there is redness of the skin; the pain is more severe; 
and it is so much aggravated by the motion of the parts, that the 
patient keeps the joint constantly in the same position, and usu- 



SYNOVIAL MEMBRANES OF JOINTS. 23 

ally in an intermediate state between that of flexion and ex- 
tension. In addition to these symptoms, there is more or less 
of symptomatic fever of the inflammatory kind. In a few 
days the disease, if left to itself, assumes the chronic form; or, 
perhaps under proper treatment, it subsides altogether. 

It must be observed, however, that the boundaries of acute 
and chronic inflammation do not admit of being very well 
defined. These terms accurately enough express the two ex- 
tremes; but there are numerous intermediate degrees of inflam- 
mation, of which it is difficult to determine whether they should 
be considered as being of the acute or chronic kind. On this, 
and on many other occasions, the pathologist must be content 
if he can succeed in pointing out the principal varieties of 
morbid action which occur, and the symptoms, which they 
produce, in such a manner as will enable others, with the as- 
sistance of a certain degree of original observation, to distin- 
guish those nicer shades in the characters of disease, which 
language is inadequate to explain, but a knowledge of which 
is of considerable importance in medical and surgical practice. 

It is to be supposed, that the character which inflammation 
of the synovial membrane assumes must, in a great degree, 
depend on the peculiar constitution of the patient. It is, how- 
ever, modified by a variety of other circumstances. 

I have already observed, that the symptoms are, for the most 
part, more severe, and that there is a greater disposition to ter- 
minate in the effusion of coagulated lymph, and thickening of 
the synovial membrane, where the inflammation is strictly lo- 
cal, than where it is the result of some disease affecting the ge 
neral system. 

In syphilitic cases, it seldom happens that more than one or 
two joints are affected at the same time. In the early stage of 
syphilis, the inflammation is usually an accompaniment of a 
papular eruption or lichen. There is then but little pain; fluid 
is effused only in small quantity; and when this has become ab- 
sorbed, the joint is restored, as nearly as possible, to its original 
condition. In the more advanced stage of syphilis, we find it 
existing in combination with nodes: and here it is productive 
altogether of much more inconvenience to the patient; is more 
difficult to be relieved; and the synovial membrane is left 
thickened, and the joint somewhat larger than natural, after the 



24 ON INFLAMMATION OP THE 

fluid has disappeared. In cases of the last description, it is 
often impossible to determine, whether the disease may with 
most reason be attributed to the agency of the syphilitic poison, 
or to the repeated exhibition of mercury. 

In cases of rheumatism, several joints are frequently affected, 
either at the same time, or in succession; and the synovial 
membranes which constitute the barsse mucosas and sheaths of 
the tendons, often participate in the disease. There is usually 
a good deal of pain and swelling, and the joints are often left 
stiff and enlarged afterwards. Where the inflammation is con- 
nected with gout, the pain is generally out of all proportion 
to the other symptoms of inflammation; and the patient com- 
pares his sensations to those, which might be supposed to arise 
if the joint were compressed by a vice, or if it were violently 
torn open. 

There is a remarkable, yet not uncommon form of the dis- 
ease, w 7 hich may be considered as bearing a relation to both gout 
and rheumatism, but differing from them, nevertheless, in some 
essential circumstances. The synovial membrane becomes 
thickened, so as to occasion considerable enlargement of the 
joints, and stiffness, there being at the same time but little dis- 
position to the effusion of fluid. In the first instance, the dis- 
ease is often confined to the fingers; afterwards it extends to 
the knees and wrists; perhaps to nearly all the joints of the 
body. Throughout its whole course, the patient complains of 
but little pain; but he suffers, nevertheless, great inconvenience, 
in consequence of the gradually increasing rigidity of the joints, 
and the number which are affected in succession. The progress 
of the disease is usually very slow, and many years may elapse 
before it reaches what may be regarded as its most advanced 
stage. Sometimes, after having reached a certain point, it re- 
mains stationary, or even some degree of amendment may 
take place: I do not, however, remember any case in which 
it could be said that an actual cure had been effected. The in- 
dividuals who suffer in the way which has been described, are, 
for the most part, those belonging to the higher classes of so- 
ciety, taking but little exercise, and leading luxurious lives: 
but there are exceptions to this rule; and the disease occasion- 
ally occurs in hospital practice, — in men, and even in females, 
of active and temperate habits. 



SYNOVIAL MEMBRANES OF JOINTS. 25 



SECTION III. 



ON THE TREATMENT OF THIS DISEASE. 

In cases in which inflammation of the synovial membrane is 
connected with rheumatism, those remedies may be employed 
with advantage, which are useful in relieving rheumatism in 
other textures; such as opium combined with ipecacuanha, or 
other diaphoretics; preparations of the colchicum autumnale and 
mercury. Of the two latter, I have found reason to believe that 
the colchicum is to be preferred, where several joints are affected, 
and where the synovial membranes, which constitute the burscz 
mucosas and sheaths of the tendons, participate in the disease. 
In such cases, the wine of the root of colchicum may be admi- 
nistered in doses varying from 15 to 30 minims, three times 
daily, or, in some instances, the acetous extract of colchicum 
may be given in alterative doses of 2 or 3 grains every night. 
On the other hand, mercury is preferable where only one or two 
joints are affected at a time; but where there has been a mani- 
fest translation of the disease, either from some internal organ, 
or from one joint to another, — the form of mercury most ge- 
nerally useful, under these circumstances, is that of calomel 
combined with opium; and it should be administered in such 
doses as to affect the gums, or to produce some other indication 
of its action on the general system. 

In those cases in which the patient complains of an excru- 
ciating grinding pain, or of a sensation as if the joint were torn 
open, and in which I have already stated that the disease pro- 
bably bears some relation to gout, the relief produced by the 
exhibition of colchicum is even more remarkable than in cases 
of rheumatism; being, in some instances, almost immediate, 
after leeches and other remedies have been employed to no pur- 
pose. 

Where inflammation of the synovial membrane arises from 
syphilis, it will probably disappear under a well-regulated 
course of mercury; and where it seems to have arisen from the 
protracted or injudicious use of mercury, or from mercury act- 

3* 



26 ON INFLAMMATION OP THE 

ing on a peculiar constitution, sarsaparilla may be given with 
advantage. This last medicine is especially useful where the 
affection of the joints occurs in combination with diseases of the 
bones and periosteum. 

In cases of that peculiar chronic disease, which is described 
in the concluding part of the last section, in which many joints, 
and sometimes nearly all the joints of the extremities are affected 
in succession, it is of importance that the greatest attention 
should be paid to the general health, so that it may be main- 
tained in as good a state as possible. As long as he is capable 
of doing so, the patient should take sufficient exercise daily, to 
induce a moderate degree of perspiration; he should live on a 
simple diet, avoiding especially raw fruit and acids, and what- 
ever is not of easy digestion ; and taking fermented liquors only 
in small quantity. The bowels should be kept gently open by 
means of rhubarb, or compound decoction of aloes, or some 
other of the same class of aperients. It has appeared to me 
also, that in these cases, patients have derived benefit from the 
use of the acetous extract of colchicum, exhibited at intervals of 
six or eight weeks, for ten or twelve successive nights, in small 
or alterative doses; and still more from very long-continued 
use of alkalis. The carbonate of potash usually agrees with the 
stomach better than the pure potash. Ten or fifteen grains 
may be given twice daily, in the middle of the day and even- 
ing, and continued, with occasional brief intermissions, for many 
months. 

In some of these cases I have known considerable improve- 
ment to take place under the use of an excellent medicine 
which has been long discarded from the London Pharmacopoeia, 
although it is retained in that of Dublin, under the name of 
Aqua calcis composita. Half a pint of this infusion may be 
taken daily for two or three successive months; then omitted for 
a short time, but taken again afterwards. It has been said that 
the hydriodate of potash also has been administered with ad- 
vantage. 

But our sole dependence must not be placed on what may 
be called specific remedies. The treatment employed in ordi- 
nary cases of' inflammation is often sufficient to effect a cure, 
and ought in no case to be altogether neglected. 

In the acute form of the inflammation, leeches may be ap- 



SYNOVIAL MEMBRANES OF JOINTS. 27 

plied in the neighbourhood of the part affected; and if there be 
much symptomatic fever, blood may be taken from the arm, 
and the bleeding may, or may not, be repeated, according to 
circumstances. Attention should be paid to the state of the 
bowels, and saline draughts may be given with some diaphoretic 
medicines. If the swelling has rapidly risen to such a height 
as to occasion considerable tension of the soft parts, the pain 
will be best relieved by means of warm fomentations and poul- 
tices; but otherwise, cold evaporating lotions seem to produce 
a better effect. Under this treatment the acute inflammation 
of the synovial membrane is in general very speedily relieved. 
The chronic inflammation is relieved more slowly. In the 
first instance, the joint should be kept in a state of perfect 
quietude. Blood should be taken from the part, by means of 
leeches or cupping. The latter method is preferable; the sud- 
den abstraction of blood, which can be thus effected, being more 
beneficial than the more gradual haemorrhage which is procured 
by leeches. It will in general be right to repeat the blood- 
letting twice or three times, or even oftener; and in the inter- 
vals, compresses may be laid on the part, moistened with some 
cold lotion. When the inflammation has been in great measure 
subdued, a blister may be applied; and, if necessary, several 
blisters may be employed in succession, with more advantage 
than a single blister kept open by means of savine cerate. The 
blisters should be of a considerable size; and if the affected joint 
be deep-seated, they may be applied as near to it as possible; 
but otherwise, a blister is frequently of more service when ap- 
plied at a little distance. For example, if the synovial mem- 
brane of the hip be inflamed, the blister may be placed on the 
groin or nates; and if the disease be in the wrist, it may be ap- 
plied to the lower part of the fore-arm. The good effects of 
this treatment are soon manifest; and in a few days the swell- 
ing, as far as it depends on fluid collected in the joint, is usual- 
ly much diminished. Even when the tumour is solid, arising 
from the effusion of coagulated lymph, it will in a considerable 
degree subside, and sometimes be entirely dispersed, provided 
that the lymph has not yet become organized. Blisters are of 
more service, with respect to the removal of the swelling, than 
any other remedies; but they should not be employed without 
the previous abstraction of blood, except when the inflamma- 



28 ON INFLAMMATION OF THE 

tion is slight, and when fluid is effused without any admixture 
of solid substance. 

When I have seen the knee joint much distended, 1 have, in 
some instances, ventured to evacuate the fluid by puncture; 
and the following is the result of my experience as to the effects 
of this operation : — 

1st. In a thin person, if a few punctures be made with an 
instrument, a very little broader than a couching needle, by 
means of an exhausted cupping glass applied over the punc- 
tures, a large quantity of fluid may be easily abstracted without 
the smallest danger, and with no inconsiderable relief to the 
patient. But, while inflammation exists, the relief is not per- 
manent, the fluid being rapidly regenerated; so that in a day or 
two, or perhaps in a few hours, the swelling is as large as ever. 
If, on the other hand, the inflammation be already subdued, the 
absorption of the fluid usually goes on so rapidly, that any more 
expeditious method of removing it is unnecessary. 2dly, If 
suppuration has taken place in the joint, (not in consequence 
of ulceration, but from the surface of the synovial membrane,) 
a free opening made into it with a lancet will often be attended 
with the best effects. I shall have occasion to advert to this 
subject again hereafter. 

When the inflammation is in great measure relieved, lini- 
ments, which irritate the skin, may be rubbed on twice or three 
times in the day. Most of the liniments of the Pharmacopoeia 
are not sufficiently stimulating for this, nor indeed for other 
purposes. The Unimentum camphorce compositum may be em- 
ployed pure; or the Unimentum saponis may be made stronger 
by the addition of liquor ammoniac and tinctura lyttce; and the 
powers of the Unimentum ammonim may be augmented in the 
same manner, or by the addition of the oleum terebinthinw. The 
following liniment is more stimulating than those ifi common 
use; and as its effects, are more permanent, it seems to me, in 
many cases, to be productive of better effects, with respect to 
the disease: — 

$< Olei Olivsegiss. 

Acidi Sulphurici giss. 
Olei Terebinthinje ^ss. 
Fiat linimentum. 

It may be used of this strength for the class of persons who 

apply at an hospital for relief; but for those of a higher class in 



SYNOVIAL MEMBRANES OP JOINTS. 29 

society, in whom the cuticle is generally thinner, and the cutis 
more tender, the proportion of the sulphuric acid should be 
somewhat less. The effect of this liniment is to excite some 
degree of inflammation of the skin: the cuticle becomes of a 
brown colour, and separates in thick, broad scales; and the in- 
flammation of the internal parts is relieved, on the same prin- 
ciple as by a blister. Another liniment, which is also very 
useful, is one frequently recommended, consisting of a dram 
(or more) of the antimonium tartarisatum mixed with an ounce 
of the unguentum cetacei. This produces a pustular eruption of 
the skin; which, like other eruptions of the same kind, runs its 
course, and, during a certain period of time, operates very 
beneficially by abstracting the inflammation from the other 
parts. 

Stimulating plasters, such as the emplastrum ttmmoniaci cum 
hydrargyro, act on the same principle as stimulating liniments, 
and are useful under the same circumstances, but they are, on 
the whole, a less convenient application. 

Issues and setons may be of some service in chronic cases, in 
abating the symptoms of inflammation of the synovial mem- 
brane; but they are more especially beneficial where there is 
reason to believe that a secondary disease has begun to exist in 
the form of ulceration of the cartilages; and of their use, under 
these circumstances, I shall have occasion to speak hereafter. 

No other active, remedies seem to be productive of much 
benefit. But a great deal may be accomplished by mere nega- 
tive treatment. Not only in cases of inflammation of the sy- 
novial membrane, but in all other cases in which actual disease 
of a joint exists, the disease, whatever it may be, is kept up 
and aggravated by motion and exercise; and whatever means 
can be employed to keep the joint in a state of complete repose, 
will go far towards the production of a cure. In the early stage 
of acute inflammation of the synovial membrane, indeed, no 
interference on the part of the surgeon is necessary for this 
purpose; the pain which the patient experiences on every at- 
tempt made to use the limb being sufficient to prevent him 
using it. But it is otherwise when the inflammation has in a 
great degree subsided. At this period the motion of the joint 
occasions little or no inconvenience at the time, although it in- 
variably tends to aggravate the symptoms afterwards. It is 



30 ON INFLAMMATION OF THE 

difficult to persuade a patient thus situated to submit to a very 
rigid system of confinement; and if he should do so, there is 
always danger, in protracted cases, that his general health may 
suffer in consequence. It is important that he should not be 
altogether deprived of the opportunity of taking air and exer- 
cise, yet it is necessary that the affected joint should be kept 
in a state approaching as nearly as possible to one of complete 
repose. This double object may be attained by means of a 
proper bandage, applied so as to restrain the motions of the 
joint, at the same time that it makes no more than a moderate 
degree of pressure on it. As to the best mode of carrying this 
plan into execution, the surgeon must exercise his own judg- 
ment in each individual case. If the disease be far advanced, 
and there is danger of the cartilages being ulcerated, he will 
find it prudent to restrain the motions of the joint altogether, 
by the application of splints of pasteboard or leather,* confined 
by a roller, or even by circular stripes of adhesive plaster on 
their outside. In other cases, the bandages, &c, recommended 
by Mr. Scott, in his ingenious w r ork on the diseases of the 
joints, will be productive of the best results. f There is a band- 
age which is very well suited to cases of this kind, which, in 
one part of its circumference, is composed of a stiff leather, 

* Splints of leather are much superior to those made of any other material 
in cases of diseased joints. They should be made of thick cow-hide, prepared 
without any kind of grease. Being cut of a proper shape, they should be 
softened in hot (not boiling) water; then moulded to the joint, and retained 
by means of a bandage. When dry they may be lined with some other soft 
leather, on the inside of which, in cases of abscess, there may be placed ano- 
ther lining of oiled silk, or of muslin prepared with caoutchouc, to prevent 
them being injured by the discharge. As they exactly fit the part which 
they are intended to support, they are quite easy to be worn. They are 
readily removed and re-adjusted, — and this is a great advantage, especially 
where there are open sinuses. I am indebted for this most excellent and 
useful contrivance to Mr. Sparkes, Bandage-maker, of Conduit Street. 

t A very convenient mode of applying bandages in these cases is as fol- 
lows: — Let it be supposed that the disease is in the knee. Circular stripes 
of leather spread with the emplastrum plumbi are to be applied round the joint, 
and extending some way above and below it; care being taken that a space 
is left for the patella, on which there ought to be as little pressure as possible. 
Over this a calico roller (four or five yards for an adult) may be applied, and 
over this again a few circular stripes of linen, spread with adhesive plaster* 
with another calico roller over the whole. A bandage of this kind, carefully 
adjusted, may not require to be changed for six or eight weeks 3 and is very 
convenient to the patient. 



SYNOVIAL MEMBRANES OP JOINTS. 31 

elsewhere of an elastic material, and secured by a lace or 
buckles, so that it admits of being applied with any degree of 
tightness. If the seat of the disease be in the knee, there 
may be a single piece of leather adapted to the shape of the 
posterior part of the limb; if it be in the elbow, there may be 
a double piece of leather, one on each side, and thus the con- 
struction of it may be varied so as to adapt it to any of the 
oiher articulations. In some instances much support may be 
wanted, and the leather should be stiff and unyielding: extend- 
ing a considerable way above and below the joint. In others, 
where little support is necessary, the leather may be more 
pliant, and it need not extend beyond the immediate neigh- 
bourhood of the part affected. Such a bandage is worn with 
the greatest comfort, and it fully answers the intended purpose. 
As it may be removed or applied by the patient's own hands, 
the use of it is quite compatible with that of the stimulating 
liniments which I have formerly mentioned.* 

After inflammation of the synovial membrane has entirely 
subsided, if we find the joint with its mobility only in a slight 
degree impaired, we may very safely leave it to itself. Time, 
and the restorative power of the constitution, will complete 
the cure. But if there be considerable stiffness and thickening 
of the soft parts, a further application of blisters will be useful 
in promoting the absorption of the lymph which has been ef- 
fused. I have also known much benefit to arise under these 
circumstances, from the use of moxa in the way recommended 
by the late Mr. Boyle; that is, the application of it being so 
managed, that the heat may penetrate into the soft parts, with- 
out making an eschar, and scarcely making a blister. 

At a still later period, friction made by the hand, with starch, 
or other fine powder, will be productive of great advantage. 

Friction, however, should be employed with caution, as, 
when used too freely, it sometimes occasions a return of the 
inflammation. Whenever there is the slightest indication of 
this being the case, it should be omitted, blood should be taken 
from the part, and some time should elapse before the friction 
is resumed. Friction is sometimes productive of very essen- 
tial benefit, but not unless it be employed to a considerable 

* Bandages of this kind are made by Shoolbred and Co., in Jermyn Street ; 
and by Sparks, in Conduit Street, London. 



32 ON INFLAMMATION OF THE 

extent; that is, for two or three hours daily, and during a long 
period of time. It is, however, a remedy which is applicable 
only under certain circumstances. We must always bear in 
mind that friction is useful in relieving some of the effects of 
disease, but not disease itself; and those who recommend it 
without attention to this principle, in these and in other cases 
will often find it to be productive of very injurious conse- 
quences. 

I have sometimes tried the effect of pumping hot water on a 
stiff joint, as recommended by Le Dran, and as now practised 
at some watering places. The blow of a column of water, 
falling from a height of several feet, produces considerable 
friction, even so as to excoriate the surface, with which are 
combined the relaxing powers of heat and moisture. This 
practice is certainly productive of benefit; but the observations 
just made apply to this as well as the other modes of producing 
friction. 

Whenever friction is useful, the vapour bath is useful also. 
The joint may be alternately bent, and extended, rubbed and 
champooed, while it is in the bath, and a degree of force may 
be applied to it, under these circumstances, which it would be 
unsafe to employ otherwise. All these methods of treatment, 
however, require time, and the exercise of much patience; 
and whoever expects the stiffness consequent on a severe attack 
of inflammation of the synovial membrane to be speedily re- 
moved, will not fail to be disappointed. In some cases, where 
the inflammation has been unusually severe, or of unusually 
long continuance, complete anchylosis having taken place, no 
plan of treatment can be successful in restoring the motions of 
the joint, and the patient must submit to the inconvenience of 
a stiff joint ever afterwards. 



The foregoing observations sufficiently explain the treatment 
to be pursued in ordinary cases of inflammation of the synovial 
membrane. Those which follow are intended to apply to the 
more rare cases, in which the disease proceeds rapidly to sup- 
puration, and the destruction of the joint. However formida- 
ble such cases may be, they are much under the control of art 
so that the patient will in many instances recover, preserving 



SYNOVIAL MEMBRANES OF JOINTS. 33 

the limb, but not the motion of the joint, which remains im- 
movable. 

If it be a question whether a collection of fluid in a joint be 
purulent or otherwise, it is prudent, in the first instance, to 
make a puncture with a grooved needle. If it prove to be pu- 
rulent, a free opening should then at once be made with a lancet 
in a depending situation. It is important that this operation 
should not be long delayed, lest the matter should make its 
way out of the joint in other directions, and form irregular 
sinuses among the neighbouring tendons and muscles. It is 
equally important that the opening should be sufficiently large 
to allow the matter to flow out spontaneously, without it being 
necessary to have recourse to pressure on the joint. If after- 
wards there be reason to believe that there is still a lodgment 
of matter in any part of the joint, or among the neighbouring 
soft parts, the original opening should be dilated, or the sur- 
geon should avail himself of the first opportunity, which oc- 
curs, of making another opening in a convenient situation; and 
it will generally happen that several such operations will be 
required before the cure is completed. 

But all this will be of little avail, unless the joint be kept in 
a state of the most complete immobility. At first we can do 
little more than support the limb on a pillow, and endeavour 
to impress on the patient's mind the necessity of his aiding our 
view's in this respect. Afterwards w r e may with great advan- 
tage apply some kind of splints: those made of leather being 
preferable to others. At the same time great attention should 
be paid to the state of the general health in all respects: saline 
medicines, or tonics, with mineral acids, being administered 
according to circumstances. Of course care must be taken to 
prevent costiveness; but on this, as on all other occasions, 
where perfect quietude is required, very active cathartics should 
be avoided. 

Under this treatment we may expect to find the purulent 
discharge lessen by degrees, and at last cease altogether, as 
anchylosis becomes established. Before anchylosis is complete, 
the surgeon should endeavour cautiously and gradually to place 
the limb in that position which may be most convenient to the 
patient afterwards: thus, if the elbow be the seat of the disease, 
it ought, if possible, to be anchylosed in a state of flexion: or, 
4 



34 ON INFLAMMATION OF THE 

if it be the knee, the leg should be nearly, but not quite, ex- 
tended as the thigh. It will be sometimes necessary to apply 
splints of different forms at different periods. Where the knee 
has been affected, I have sometimes employed a wooden splint, 
consisting of two parts, one adapted to the posterior part of the 
thigh, the other to the posterior part of the leg, united by a 
hinge, and furnished with a long screw behind, by means of 
which the relative position of the leg and thigh may be daily 
and almost imperceptibly altered. 

It may be almost unnecessary to remark that the chance of 
recovery in these cases must vary very much, accordingly as 
one or another joint has been the seat of the inflammation. 
The rapid formation of matter within the unyielding capsule 
of the hip-joint is especially dangerous, on account of the urgent 
constitutional symptoms to which it gives rise, and also for this 
reason, that it is impossible to ascertain the exact nature of the 
mischief which exists, or, if it were ascertained, to relieve the 
patient by making an opening into the articular cavity. It is 
also reasonable to suppose that suppuration of the synovial 
membranes belonging to the complicated joints of the carpus 
and tarsus must be more dangerous than that of the synovial 
membrane of the more simple joints of the knee and elbow. 



SECTION IV. 

CASES OF INFLAMED SYNOVIAL MEMBRANE. 

The cases which I am about to relate will serve to illustrate 
the observations respecting the inflammation of the synovial 
membranes which I have already made; and also to explain 
some circumstances which will be found to occur in practice, 
and which could not have been so well introduced in the general 
history of the disease contained in the preceding pages. Who- 
ever will take the pains to compare these cases with each other, 
and with those which I shall relate hereafter, will, if I am not 
exceedingly mistaken, be convinced that the classification of 
the different diseases of the joints is not a mere matter of cu- 



SYNOVIAL MEMBRANES OF JOINTS. 35 

riosity, which may be interesting to the morbid anatomist; but 
that these diseases are different in their progress; that they 
produce different symptoms, by which they may be distin- 
guished from each other in the living person, and which indi- 
cate the employment of different remedies for their relief. 

CASE V. 

John Adams, forty-seven years of age, on the 21st of Au- 
gust, 1811, was seized with a pain in his left knee, and in the 
course of a few hours he found the joint to be swollen. This 
was accompanied by a slight attack of fever. 

On the 28th of August he was admitted into St. George's 
Hospital. At this time the knee was extremely painful and 
tender, and much swollen; the swelling not having the form of 
the articulating ends of the bones, but being most prominent 
on the anterior and lower part of the thigh, underneath the 
lower portion of the extensor muscles. The fluctuation of fluid 
might be distinctly felt within the synovial membrane. 

Eight ounces of blood were taken from the knee by cupping. 
The loss of blood was immediately followed by an abatement 
of the pain, tenderness, and swelling. On the 30th of August 
a blister was applied. 

The cupping was repeated on the 9th and ISth of September, 
and on the 4th of October; and each time was followed by the 
application of a blister. 

On the 10th of October the joint was free from all pain and 
tenderness. It was stifi*, and still slightly swollen; but no fluid 
was perceptible, the swelling appearing to arise entirely from 
solid substance. He was directed to use a stimulating liniment 
twice in the day. 

On the 18th of October there had been no return of the in- 
flammation, and the stiffness and swelling were diminished. 
Friction was now employed, by means of the hand, with starch 
powder, every morning and evening; and in a few days after- 
wards, it was directed, in addition to the friction, that hot water 
should be pumped on the joint, so as to fall on it from a height 
of several feet for half an hour every morning. 

About the middle of November he was dismissed from the 
hospital; the joint being now nearly as small, and as moveable 
as before the inflammation had taken place. 



36 ON INFLAMMATION OF THE 

CASE VI. 

Robert Stewart, eighteen years of age, was admitted into St. 
George's Hospital on the 26th of January, 1814. 

He said that, about seven weeks before his admission, the 
right knee had become swollen and painful, without any evi- 
dent cause. The pain and swelling took place about the same 
time. The pain was severe, and attended with some degree of 
fever. About a fortnight before his admission, the joint was 
cupped, and the swelling and pain became much diminished, 
and the leg more moveable. The cupping had been repeated 
on the day previous to his coming to the hospital, and again 
afforded him relief. 

At the time of his being admitted into the hospital, the knee 
was still much swollen, the swelling extending up the anterior 
and lower part of the thigh under the extensor muscles; and it 
appeared to arise chiefly from solid substance effused within 
the articulation, very little fluid being to be distinguished. 
There was but little pain or tenderness; the joint admitted of 
a. limited motion: he said it was less stiff than it had been a 
short time before. 

On the 27th of January eight ounces of blood were taken 
from the knee by cupping, and afterwards a blister was applied. 

On the 5th of February the blister was healed. The swell- 
ing was much diminished. The solid substance, which had 
been effused, was in great measure absorbed; so that the form 
of the articulating ends of the bones could be distinguished. 
The blister was repeated. 

On the 18th of February the joint was scarcely larger than 
natural, but it was still stiff in a slight degree. The stiffness 
disappeared under the employment of friction with mercurial 
ointment and camphor, and on the 23d of February he was 
dismissed from the hospital as cured. 

CASE VII. 

John Hannam, a stout middle-aged man, was admitted into 
St. George's Hospital, under Mr. Keate, on the 22d of May, 
1811. 

He said that, six years ago, he had wrenched his right knee, 
which in a few hours became swollen and painful. In the 
course of a month the pain and the swelling subsided, and he 



SYNOVIAL MEMBRANES OF JOINTS. 37 

returned to his duty as a soldier, in one of the regiments of 
Life Guards: but from that period he experienced what he 
termed a weakness of the joint; and he had a return of pain 
and swelling whenever he made any unusual exertion. A 
year and a half previously to his coming to the hospital, he was 
ill of a fever. From this time the knee was more swollen and 
painful; and he continued in this state, sometimes better, some- 
times worse; so that he was unable to do his duty, and he was 
in consequence discharged from his regiment. 

At the time of his admission the knee was swollen; partly 
from fluid in its cavity, partly from thickening of the soft parts. 
The swelling extended some way up the anterior part of the 
thigh, and was prominent on each side of the ligament of the 
patella. The joint was stiff, but admitted of an imperfect flex- 
ion and extension. He complained of some degree of pain 
when at rest; but the pain was more severe whenever he at- 
tempted to exercise the limb. There was an enlarged lympha- 
tic gland in the groin. 

The knee was cupped several times, and always w 7 ith advan- 
tage. Blisters and stimulating liniments were employed, and 
about the end of September he left the hospital, better than 
when he was admitted; but there w r as still pain whenever he 
made any unusual exertion, and the joint was swollen and stiff, 
though in a less degree than formerly. The swelling now ap- 
peared to arise altogether from solid substance, no fluid being 
perceptible. 

Fifteen months afterwards, I had an opportunity of seeing 
the patient again. There was very little alteration in the state 
of the knee. He said that whenever he took more exercise 
than usual, or was exposed to cold, inflammation took place, 
and the swelling was increased; but that, by remaining for a 
short time in a state of quietude, these symptoms were always 
relieved. 



The three preceding cases are sufficient to illustrate the ordi- 
nary characters, and the ordinary progress of this disease. 
Those which follow are intended to explain certain circum- 
stances, which, although of less frequent occurrence, are occa- 
sionally met with, and which it is of much consequence for 
the surgeon to understand. 




3S ON INFLAMMATION OF THE 

CASE VIII. 

A young gentleman, about thirteen years of age, in July, 
1S17, was seized with inflammation of the synovial membrane 
of one knee, attended with the usual symptoms. Blood was 
taken from the knee by means of leeches and cupping, cold 
lotions were applied, and the violence of the inflammation sub- 
sided. In the beginning of October a blister was applied; and 
at the end of October the knee was in the following state. It 
was larger than the other; the swelling having the form of the 
articulating extremities of the bones, and appearing to arise 
from a thickened state of the synovial membrane. The joint 
admitted only of a limited degree of motion, and the motion, 
of it beyond a certain point was productive of pain. He was 
now directed to employ friction with a stimulating liniment. 

The complaint continued very nearly in the same condition 
until the middle of November, when the swelling became sud- 
denly reduced, and almost wholly disappeared. But on the 
same day he complained of an acute pain in his head, shooting 
from the temples to the forehead just above the eyebrow. This 
pain went off in a few hours, leaving only a slight soreness; 
and for several days it returned periodically, in the form of a 
nocturnal paroxysm, of great severity, but of only a few mi- 
nutes' duration. Leeches and blisters were applied both to the 
head and legs; and purgatives were administered. At the end 
of a week the pain ceased; but he was seized with great som- 
nolency, which was soon followed by strabismus, partial blind- 
ness, and almost total cessation of speech; and after remaining 
in this state about a week, he died. 

The body was not examined. 

CASE IX. 

James Burton, forty years of age, was admitted into St. 
George's Hospital, on the 2d of June, 1813, labouring under 
a complaint of his left knee. He said that, two years ago, the 
joint became painful and swollen, at first in a slight degree, but 
afterwards the pain and swelling increased; and he observed 
that the symptoms were always aggravated on the coming on 
of cold or wet weather. For the last nine months he had been 



SYNOVIAL MEMBRANES OF JOINTS. 39 

unable to use the joint sufficiently to enable him to attend to 
his usual occupations. Blisters and issues had been employed 
at various times, and, as he thought, with some temporary re- 
lief. At the time of his admission the knee was swollen, in 
consequence of fluid being collected within the cavity of the 

jovial membrane. The fluid might be distinctly felt to fluc- 
tuate underneath the patella when the two hands were placed, 
one on each side of the joint. The soft parts were somewhat, 
but not considerably, thickened. He had very little pain ex- 
cept on motion; was unable to bend the leg beyond the right 
angle, but could extend it completely. The swelling of the 
joint appeared greater than it really was, on account of the 
wasting of the muscles of the thigh and leg. 

Blood was taken from the knee by cupping; and afterwards 
several blisters were applied in succession. He took five grains 
of the pihrfa hydrargyri submuriaiis composite* every night. On 
the 2d of August a blister was applied, and kept open by dress- 
ing it with the savine cerate. At the end of three weeks he 
complained of pain, and a sense of irritation, extending up the 
thigh and down the leg. These symptoms were attributed to 
the open blister, and were immediately relieved when the 
blistered surface was allowed to skin over. On the 50th of 
September he quitted the hospital, being free from all his for- 
mer symptoms, except that there was still a slight degree of 
stiffness of the joint. 

In the beginning of July, 1515, the same patient came again 
under my observation. At this time, both knees were distend- 
ed with fluid; the right shoulder was swollen, but in a less de- 
gree; and there was a collection of fluid in the synovial mem- 
brane which forms the sheath of the tendons on the posterior 
part of each wrist. On examining the right knee, which was 
the most swollen of the two, a sensation was communicated to 
the hand, as if produced by a number of small loose substances, 
of a soft consistence, within the cavity of the joint, and just 
perceptible to the touch. The joints were moveable, and very 
little painful. He said that all these swellings had begun about 
three months after he formerly quitted the hospital, with a 
slight degree of pain, and had gradually increased.* 

* These cases are given as they stood in the former editions of this work, 
and they sufficiently illustrate the principal circumstances in the history of 



40 ON INFLAMMATION OF THE 

I suspect the loose substances, which were felt within the 
knee in this case, to have been portions of coagulated lymph, 
which had been effused on the inner surface of the synovial 
membrane, and afterwards had become detached ; similar to those 
which are sometimes formed in the cavity of an inflamed bursa 
mucosa, and which 1 shall have occasion to describe hereafter. 
I had not the opportunity of observing the subsequent progress 
of the disease in this patient; and I have never been able to as- 
certain the correctness or incorrectness of this opinion, respect- 
ing these loose substances, by dissection. They are certainly 
of a different nature from the loose cartilages which are met 
with in other cases. 

CASE X. 

Amy Brookes, fifty-four years of age, was admitted into St. 
George's Hospital on the 10th of June, 1818. Three years 
ago, her right knee became sw 7 ollen and painful, and the pain 
and swelling had existed ever since, sometimes in a greater, 
sometimes in a less degree. At the time of her admission, the 
knee was much swollen, in consequence of fluid collected in 
its cavity. There was pain in the joint, which was aggravated 
by motion; but which was not sufficient to interfere with her 
rest at night, or to prevent her going about her usual occupa- 
tions. On examining the knee, a sensation was given to the 
hand, as if some soft loose substance was formed within the 
joint; and a crepitus was distinguished, on moving the patella 
from one side to the other. 

During the time of her stay in the hospital, blood was taken 
from the knee twice by cupping, and once by leeches; and two 
blisters were applied. July 15th, she was discharged as cured; 
there was no pain nor swelling; the loose substance was no 
longer perceptible, and the crepitus could scarcely be distin- 
guished. 

The crepitus which was observed in this case, occurs in a 

the disease. But it should be observed, with respect to some of them, (that 
of Burton and of Hannam, for example,) that the practice employed in St. 
George's Hospital for some years past would have been, after the inflamma- 
tion had subsided, to apply pasteboard splints or bandages, so as to restrain 
the motions of the joint, and that there is no doubt that the recovery of the 
patients under this treatment would have been more rapid and more com- 
plete. 






. 



SYNOVIAL MEMBRANES OF JOINTS. 41 

few instances, and I know not positively to what cause it is to 
be attributed. It is different from that which I have met with, 
where there has been reason to believe that the cartilages are 
destroyed, so as to expose the bone underneath; and if this had 
been the cause of it, we must suppose that it would have been 
permanent, or at any rate, of longer duration. Probably it 
may have depended, in this case, on an effusion of albumen 
(coagulated lymph,) or on the synovia having been secreted of 
a different quality from what is usual. 

The following case affords an example of inflammation of 
the synovial membrane of the hip terminating in dislocation. 

CASE XI. 

Master L., being at that time about eight years of age, was 
attacked, towards the end of September, 1S24, with what was 
believed at the time to be inflammation of one of the parotid 
glands, attended, with a good deal of fever. After six or seven 
days, and apparently in consequence of the application of cold 
lotions to the cheek, the inflammation left the parotid gland, 
and attacked one shoulder and arm; and at the end of two or 
three days more it left the shoulder and attacked one of the hips. 
For six or eight weeks he suffered most severely from pain 
referred to the inside of the thigh, extending from the pubes as 
low down as within two or three inches of the inner condyle 
of the femur, and attended with a great deal of fever. There 
was no pain in the knee. The surgeon, who was then in at- 
tendance, applied leeches to the hip, lotions, &c, and afterwards 
made an issue with caustic behind the great trochanter. The 
fluctuation of fluid was perceived at the posterior point of the 
hip, and it was supposed that an abscess had formed. How- 
ever, no puncture was made, and the fluid gradually became 
absorbed. In March, 1825, Master L., was sufficiently reco- 
vered to be able to walk about; but it was discovered that the 
limb was shortened. In November, 1825, I was consulted re- 
specting him. At this time there were all the marks of a dis- 
location of the hip upwards and outwards. The limb was 
shortened, the toes turned inwards, and the head of the femur 
was distinctly to be felt on the posterior part of the ilium above 
the margin of the acetabulum. 



42 ON INFLAMMATION OF THE 

The following case furnishes an example of a disease, which, 
as far as I know, has not been described by any pathological or 
surgical writer. One of the most remarkable symptoms which 
the disease produces is an inflammation of the synovial mem- 
branes; for which reason it is to be regarded as connected with 
the present subject, and may be properly introduced in this 
place. 

CASE XII. 

A gentleman forty-five years of age, in the middle of June, 
1817, became affected with symptoms resembling those of go- 
norrhoea. There was a purulent discharge from the urethra, 
with ardor urince and chordee. On the 23d of June he first ex- 
perienced some degree of pain in his feet. On the 24th the 
pain in the feet was rather increased, but not in a sufficient de- 
gree to prevent his walking four miles. There was some ap- 
pearance of inflammation of his eyes. 

June 25th, the pain in his feet was more severe; the tuniccz 
conjunctivas of his eyes were much inflamed, with a profuse dis- 
charge of pus. 

These symptoms increased in violence, the pulse varying 
from 80 to 90 in a minute; the tongue being furred; and the 
patient being restless and uncomfortable during the night. 
The whole of each foot became swollen; there was inflamma- 
tion of the synovial membranes of the ankles; and it appeared 
to me, that the affection of the feet themselves arose from in- 
flammation of the synovial membranes belonging to the joints 
of the tarsus, metatarsus, and toes. He said that he could com- 
pare the pain, which he experienced, to nothing else than that 
which might be supposed to arise from the feet being squeezed 
in a vice. 

On the 27th of June the left knee became painful, and on the 
following day the synovial membrane of this joint was found 
exceedingly distended with synovia. He was now completely 
crippled; compelled to keep his bed, and scarcely able to vary 
his position in the smallest degree without assistance. The 
inflammation of the eyes and urethra was somewhat abated. 

June 30th, the inflammation of the eyes and urethra had 
much subsided, and the purulent discharge was diminished. 
The pains of his joints were less severe; and the feet w r ere less 



SYNOVIAL MEMBRANES OF JOINTS. 43 

swollen. On the following day the knee was less swollen 
also. 

He continued to mend, and on the 10th of July the swelling 
of the feet was still farther diminished, and that of the knee 
had almost wholly disappeared. His pulse continued to vary 
from SO to 90 in a minute, and his tongue was still furred. 
He had pain in the feet and knee, but less severe than formerly, 
and he was restless at night. 

July 13th, he complained, of pain in the right knee, and on 
the following day there was pain also of the right elbow and 
shoulder. 

The right knee afterwards became swollen from fluid within 
the cavity of the synovial membrane, but not in the same de- 
gree with the other knee, and the swelling soon subsided. 
There was never any perceptible swelling of the shoulder and 
elbow. 

August 1st, all his pains were abated. The eye and the 
urethra were nearly free from inflammation, and the purulent 
discharge was scarcely perceptible. 

August 5th, he was free from pain except on motion; the 
joints, which had been affected, were stiff; but he was able to 
move about on crutches. 

From this time he progressively mended. The stiffness of 
the joints diminished very slowly; but he was free from all 
uneasiness. He was longer in recovering the use of the shoul- 
der than that of the other joints. 

In the following December, 1817, (at which time he had 
nearly, but not completely, recovered the use of his limbs.) he 
had another attack of the complaint. The symptoms were the 
same as formerly, taking place in the same order, and pursuing 
the same course, but with a much less degree of violence. 
This second attack lasted about six weeks; and left him again 
considerably crippled. 

In March, 1818, he beeame affected with an ophthalmia, but 
of a different nature from that which he laboured under in the 
preceding summer. The inflammation was seated in the pro- 
per tunics of the eye; and it appeared probable that it would 
speedily have terminated in adhesions of the iris, and destruc- 
tion of the powers of vision, if its progress had not been ar- 
rested by repeated blood-lettings and the use of mercury. He 



44 ON INFLAMMATION OF THE 

had another attack of ophthalmia of the same kind four years 
afterwards (1822.) 

In order that the history of the disease might be rendered as 
simple as possible, I have described the symptoms in this case 
without hitherto adverting to the treatment which was em- 
ployed. — Leeches, and blisters to the knee; liniments rubbed 
on the knees and shoulders; and fomentations when there was 
severe pain, formed the principal topical remedies. Of the va- 
rious medicines which were exhibited, none seemed to be pro- 
ductive of benefit, with the exception of the vinum colchici. It 
was under the use of this medicine, that not only the pains and 
swellings of the joints, but that even the purulent inflammation 
of the eyes and urethra first began to subside ; and I am, on 
the whole, inclined to believe that my patient was indebted to 
it for a much more speedy recovery than he would have ob- 
tained otherwise. 



I have had the opportunity of seeing many other cases, in 
which a similar train of symptoms took place. 

One gentleman (at the time when these notes were taken) 
had suffered from as many as nine attacks of this complaint. 
The first took place when he was under twenty years of age, 
and the others at various intervals in the course of the next 
twenty years. In one of them the first symptom was inflam- 
mation of the urethra, attended with a discharge of pus, al- 
though, from particular circumstances, he could not believe that 
he had been exposed to the risk of infection. This was followed 
by purulent ophth?lmia, and that by inflammation of the syno- 
vial membranes. In three of the attacks, a purulent ophthalmia 
was the first symptom; which was followed by inflammation and 
discharge from the urethra; and then the synovial membranes 
became affected: and in the other four attacks, the affection of 
the synovial membranes took place without any preceding in- 
flammation either of the eye or urethra. The disease was not 
confined to the synovial membranes of the joints, but those of 
the bursx mucoscz were inflamed also. In some of the attacks, 
the muscles of the abdomen were painful and tender, and sub- 
ject to spasmodic contractions; and there was an occasional im- 
pediment to breathing, which seemed to arise from a similar 
affection of the diaphragm. The acute form of the disease, in 



SYNOVIAL MEMBRANES OF JOINTS. 45 

this case, lasted from six weeks to three months, but nearly a 
year generally elapsed before the use of the limbs was perfectly 
restored. He had an attack in July, 1817; and in the begin- 
ning of May, ISIS, while he was still lame, he was seized with 
a very violent inflammation of the sclerotic coat and iris of one 
eye, which was subdued by very copious blood-letting, and the 
exhibition of mercury. He had another attack of the disorder 
in the year 1820, and in the winter of 1822 he became affected 
with an inflammation of the iris and sclerotic coat of theother 
eye, which was also relieved by blood-letting and the use of 
mercury. 

Another gentleman gave the following history of his com- 
plaints. In the year 1809, he had symptoms resembling those 
of gonorrhoea; and, when these had continued for some time, 
one testicle became inflamed and swollen. This was followed 
by a purulent ophthalmia, and inflammation of the synovial 
membranes. In the year 1S14, he had a similar attack, with 
the exception of the swelled testicle; and in the year 1S16, 
when I was consulted, he still laboured under a chronic inflam- 
mation of the synovial membranes of the knees and ankles, the 
consequence of the last attack, and by which his lower limbs 
were completely crippled. 

In a fourth case, the patient laboured under a severe oph- 
thalmia, which was followed by inflammation df the urethra, 
and then the joints became affected: but I had no opportunity 
of watching the progress of this case, nor have I heard any other 
particulars of it. 

In another case, the patient laboured under strictures of the 
urethra. He had four attacks of the disease, which has been 
just described, in the course of a few years. The inflam- 
mation of the urethra was in all of them the first symptom; 
which was followed by purulent ophthalmia, and afterwards 
by inflammation of the synovial membranes, and swelling of 
nearly all the joints. In two of these attacks, he attributed the 
discharge from the urethra to his having received the infection 
of gonorrhoea, and in the two others to the use of the bougie. 

I shall conclude this chapter with the histories of two cases, 

one of which bears a near relation to those which I have just 

described, and is introduced chiefly ^s it shows the good effects 

produced occasionally by the exhibition of the colchicum; while 

5 



46 ON INFLAMMATION OP THE 

the other affords an example of the advantage derived from the 
exhibition of mercury, under certain circumstances. 

CASE XIII. 

A gentleman twenty-three years of age, in the beginning of 
July, 1819, rode 24 miles on horseback, trotting very hard on 
account of rain. Two days afterwards he observed a slight 
swelling of the left knee; but this did not prevent his going 
about his usual occupations. About the middle of July, a slight 
purulent discharge took place from the urethra, with little or 
no pain. On the first of August, he walked a considerable 
distance, and found the knee to be more painful. On the se- 
cond of August he applied to me, w r ith the knee very much 
swollen and very painful. Twenty leeches were applied, and 
afterwards a cold lotion; but this gave him no relief. 

August 3d, the pain had much increased, so that it was ex- 
cruciating. He was bled in the arm, and was in much less pain 
afterwards. Some saline medicine with the pulv. ipec. comp. 
was administered. In the evening a blister was applied ; but 
as soon as the blister began to act the pain returned, and was 
as severe as formerly. 

August 5th, he continued suffering very much from pain. 

August 6th, the pain was very intense in the knee. The 
purulent discharge from the urethra was rather increased. 
There was a slight degree of inflammation of the tunica con- 
junctiva of the left eye. He was bled, with little or no relief. 
A saline draught, with a few grains of the pulvis ipecac, comp. 
and twenty minims of the vinum (radicis) colchici, was ad- 
ministered every six hours. When he had taken four doses of 
this medicine he became sick, and vomited, and w r as afterwards 
purged. The colchicum was discontinued. 

August 7th, he was quite free from pain, but the synovial 
membrane was much distended with fluid. 

August 15th, the knee had continued free from pain, but was 
much swollen. With a view to promote the absorption of the 
fluid, another blister was applied; but, as soon as it began to 
operate, the pain returned and was more excruciating than ever; 
and continued so on the following day, August 16th, when the 
vinum colchici was again administered. As soon as he had taken 
three doses of 20 minimS each, he was sick and purged, and 



SYNOVIAL MEMBRANES OF JOINTS. 47 

this was followed by an immediate and complete relief from 
pain. 

August 17th, he was free from pain, except on motion. 

August 18th, the swelling began to subside, and, in the course 
of a few days, it had entirely disappeared, and he was quite re- 
covered. 

The inflammation of the eye subsided, without any particular 
local treatment, in about ten days from the period of its com- 
mencement. The purulent discharge from the urethra con- 
tinued for some time afterwards. 

The pain in the knee, in this case, was of such a kind as to be 
almost insupportable. The patient said that he could compare 
it to nothing but the sensation which might be produced by the 
joint being forcibly torn open. The pulse was never accele- 
rated, except at those times when the pain was most intense. 
Purgatives and other remedies were administered in the course 
of the disease, but nothing seemed to be productive of benefit, 
except the vinum colchici. 

CASE XIV. 

John Welsh, thirty years of age, was admitted into St, 
George's Hospital, on the 21st of February, 1827, 

The right knee was much distended with fluid. He com- 
plained of constant pain in the joint, and of painful startings of 
the limb at night; by which he was frequently awakened from 
his sleep. The pain was aggravated by every motion of the 
joint, and by pressing the articulating surfaces against each 
other. The pulse beat 100 in a minute. 

He stated that, nearly five months ago, he had been a patient 
in the Middlesex Hospital, on account of an inflammatory af- 
fection of his chest; and that blisters had been at that time ap- 
plied to his side. As soon as the inflammation of the chest was 
relieved, both his knees became swollen and painful. He was 
then made an out-patient. The inflammation of the knees 
abated under the use of liniments; but towards the end of De- 
cember, 1826, the right knee became again inflamed, and con- 
tinued so until the period of his being admitted into St. George's 
Hospital. Blood was taken from the knee by cupping; and the 
pulvis ipecacuanha compositus was directed to be given every 
night. Afterwards the cupping was repeated, several blisters 



48 ON INFLAMMATION OF THE 

were applied in succession; and 3ss. of the vinum radicis colchici 
was administered three times daily for three successive days, 
after which it was discontinued on account of it having acted 
considerably on the bowels. 

Under this treatment, however, little or no amendment took 
place with respect to the local disease, and the pulse rose to 
108. 

March 17. I was led to suspect that the fluid in the joint 
might be purulent. In order to ascertain this, I punctured the 
knee with a narrow sharp-pointed instrument; and, by apply- 
ing a cupping glass over the puncture, drew off between two 
and three ounces, not of pus, but of turbid serum, with small 
flakes of coagulated lymph floating in it. 

March 20. The fluid had become again collected in the joint, 
so that the swelling was as large as ever. The pain, however, 
had been manifestly relieved by the puncture. Pulse 110. The 
man complained of pain, referred to the right ulna and to the 
forehead, which he said he had felt for the last week. 

He was directed to take the following pill, three times daily: — 

5^. Hydrargyri submuriatis, gr. ij. 
Opii gr. ss. 
Fiat pilula. 

March 27. The pains in the head and ulna were relieved. 
The knee was less swollen and painful. Pulse 100. The gums 
were beginning to be sore. It was directed that the pill should 
be taken twice daily. 

March 31. The knee was much improved. Pulse 88. It 
was ordered that the pill should be taken only once daily. 

April 10. After having been quite free from pain in the knee, 
he had a slight recurrence of it: on account of which, it was 
thought advisable to apply leeches, and afterwards a blister. 

From this time he continued to mend. 

April 28. The mercurial pills were discontinued, and soon 
afterwards he was dismissed as cured. 



SYNOVIAL MEMBRANE. 49 



CHAPTER II. 



ON ULCERATION OF THE SYNOVIAL MEMBRANE. 

When an abscess has formed in a joint, an ulcerated opening 
takes place in the synovial membrane, through which the matter 
is discharged. The following are the only cases, which have 
come under my observation, in which ulceration of the syno- 
vial membrane has occurred as a primary affection. The most 
remarkable circumstance which they demonstrate is, that a dis- 
ease apparently slight, and of a part which is in no way con- 
cerned in the vital functions, should produce such a degree of 
disturbance of the constitution, as to occasion death. Of this 
however, they form, by no means, a solitary example; and 
every surgeon and physiologist will be able to call to mind nu- 
merous other instances, which show that an impression made 
upon a small part of the nervous system may derange, and ul- 
timately destroy, the functions of the whole animal machine. 

CASE XV. 

A young lady, nine years of age, being at play on the 1st of 
January, 1808, fell and wrenched her hip. She experienced so 
little uneasiness, that she walked out on that day as usual. In 
the evening she went to a dance; but while there was seized 
with a rigor; was carried home, and put to bed. Next morn- 
ing she was much indisposed, and complained of pain in the 
thigh and knee. On the following day she had pain in the hip, 
and was very feverish. These symptoms continued; she be- 
came delirious; and she died just a week from the time of the 
accident. 

On inspecting the body on the following day, the viscera of 
the thorax and abdomen were found in a perfectly healthy state. 
The hip-joint on the side of the injury contained about half an 
ounce of dark-coloured pus; and the synovial membrane, where 
it was reflected over the neck of the femur, was destroyed by 
ulceration, for about the extent of a shilling. 

5* 



50 ON ULCERATION OF THE 

CASE XVI. 

A middle-aged man, who had met with a contusion of one 
shoulder, was admitted into St. George's Hospital in the win- 
ter of 1812. He complained of pain and tenderrfess of the 
shoulder, and a very slight degree of swelling was observable: 
but his principal disease was a fever, resembling typhus in its 
character, of which he died in a few days after his admission. 

On inspecting the body, about half an ounce of thin pus was 
found in the shoulder-joint. The synovial membrane bore 
marks of general inflammation; and in one spot, where it was 
reflected over the neck of the os brachii, it was destroyed by 
ulceration for about the extent of a sixpence. 



CHAPTER III. 



ON CASES IN WHICH THE SYNOVIAL MEMBRANE HAS UN- 
DERGONE A MORBID CHANGE OF STRUCTURE. 



SECTION I. 

PATHOLOGICAL OBSERVATIONS. 

There are some diseases, which consist simply in a morbid 
action; there are others, in which the morbid action produces 
a morbid change of anatomical structure. 

Diseases of the latter class differ in their nature in different 
organs. Thus the tubercles, which affect the lungs in phthisis 
pulmonalis, are never met with in the breast; and cancer, which 
is frequent in the breast, never attacks the lungs, except by ex- 
tending to them from the contiguous parts. 

The disease, which I am about to describe in the present 
chapter, consists in a morbid alteration of structure, which takes 
place in the synovial membranes of joints, and which, as far as 
I have seen, is peculiar to these parts. I have not in my own 



SYNOVIAL MEMBRANE. 51 

practice met with an instance of the same disease in the serous- 
membranes, which so nearly resemble the former in their na- 
ture and functions; nor even in the synovial membranes, which 
constitute the bursas mucosae and sheaths of the tendons. 

Several years since, in examining a diseased elbow, I found 
the cartilaginous surfaces completely destroyed by ulceration: 
an abscess had formed in the joint, and no remains were ob- 
servable of the natural structure of the soft parts, these being 
every where converted into a pulpy substance, of a light brown 
colour, and about one-third of an inch in thickness. As the 
ravages of the disease were very extensive, it was impossible to 
determine, from the appearances on dissection, where the mor- 
bid action had originated. This case, however, differed ma- 
terially from some others which I had met with, in which the 
destruction of the cartilages was not attended by any affection 
of the soft parts similar to that which has been described. The 
following cases, which have since occurred, furnish examples 
of the same disease in earlier stages of its progress, and show 
that it begins in the synovial membrane, and that the other 
parts become affected only in a secondary manner. 

CASE XVII. 

In a diseased knee, which was sent to me for examination by 
my friend, the late Mr. Horn, surgeon to the Newcastle Infir- 
mary, I found, in the cavity of the joint, about four ounces of 
a pale yellow fluid, having flakes of coagulated lymph floating 
in it. The synovial membrane, where it formed the loose folds, 
extending from one bone to the other; where it was reflected 
over the bones themselves, the crucial ligaments, and the fatty 
substance of the joint, had completely lost its natural appear- 
ance. It was converted into a pulpy substance, in most parts 
about a quarter, but in some parts nearly half an inch in thick- 
ness, of alight brown colour, intersected by white membranous 
lines, and with red spots formed by small vessels injected with 
their own blood. The synovial membrane on the edge of the 
cartilaginous surfaces had undergone a similar change of struc- 
ture, but only for a small extent. The semilunar cartilages 
were entire, but in a great measure concealed by the pulpy sub- 
stance projecting over them. The cartilages covering the bones, 
in a few places, were in a state of incipient ulceration. 



52 ON MORBID CHANGE OF STRUCTURE 

CASE XVIII. 

Martha Manners, twenty-six years of age, was admitted into 
St George's Hospital, on the 6th of March, 1813, on account 
of a disease in her right knee. 

She said that in June, 1811, she first observed the joint to be 
swollen and stiff; and from this time, the swelling and stiffness 
increased; but, in the first instance, by very slow degrees. 
About Michaelmas, 1812, she caught cold, and the swelling in- 
creased more rapidly; but it was not attended with any consi- 
derable degree of pain. 

At the time of her admission into the hospital, the right knee 
measured about two inches in circumference more than the 
left. The swelling was elastic; prominent at the upper and 
lower part of the joint; not having the form of the articulating 
ends of the bones. The joint admitted of motion, but the leg 
could not be completely bent or extended on the thigh. 

Various remedies were employed without the smallest bene- 
fit. The stiffness of the joint increased. About the middle of 
May, she began to experience considerable pain; and soon after- 
wards an abscess presented itself by the side of the ligament of 
the patella, which was opened on the 15th of June. The orifice 
made by the lancet healed in a few days; but she continued to 
suffer severe pain; her health became much affected, and on the 
6th of August the limb was removed by amputation. 

On examining the joint, about an ounce of thick matter was 
found in its cavity. The ligaments were in a natural state. 
The synovial membrane had undergone precisely the same al- 
teration as in the case which has just been related. The only 
point of difference that could be observed w r as, that the whole 
of that portion of the membrane which is reflected over the 
cartilages had become affected, presenting the same appearance 
as elsewhere, but being thickened in a less degree. The car- 
tilages had begun to ulcerate in a few spots; but the ulceration 
had made so little progress, that it might not have been noticed 
on a superficial inspection. 

CASE XIX. 

Samuel Langford, twenty-four years of age, was admitted into 
St. George's Hospital on the 22d of April, 1812. 



OF THE SYNOVIAL MEMBRANE. 53 

At the time of his admission one of his knees was swollen to 
nearly twice its natural size. The swelling was prominent on 
the anterior and lower part of the thigh. It was soft and elastic, 
so that at first it appeared to contain fluid; but, on particular ex- 
amination, the absence of fluid was ascertained by the want of 
fluctuation. The leg was kept in the half-bent state, and the 
joint admitted of only a very limited degree of motion. He 
had no pain, even when attempts were made to move the limb. 
The skin over the diseased part was of a pale colour, with some 
dilated veins ramifying in it. On each side of the joint a small 
orifice was observed, through which the probe might be intro- 
duced into a sinus; but the sinuses appeared to be of small ex- 
tent. His general health was unimpaired. He said that, two 
years ago, he first experienced some pain in the knee, but it 
was not sufficient to prevent his going about his usual occupa- 
tions. Soon afterwards the joint began to swell, and the erw 
largement gradually increased from that period. Several ab- 
scesses had formed at different times; but the greater number 
of them had healed. 

About two months after his admission into the hospital, the 
limb was amputated. 

On dissecting the diseased joint, the ligaments were found in 
a perfectly natural state. The whole synovial membrane, ex- 
cept where it was reflected over the cartilages, was converted 
into a pulpy, elastic substance, of a brown colour, intersected by 
white membranous lines, in some places half an inch in thick- 
ness, in others more; and in those parts where the membrane 
was reflected over the bones, near the border of the cartilages, 
it was destroyed in spots by ulceration. 

The semilunar cartilages were in a natural state, but in a 
great measure concealed, in consequence of their being enve- 
loped in the mass of substance formed by the diseased synovial 
membrane. The cartilaginous surfaces of the femur and patella 
were extensively, but not entirely, destroyed by ulceration; the 
ulceration being greatest towards the circumference. On the 
internal portion of the head of the tibia, the cartilage was de- 
stroyed only for a very small extent, the ulceration being en- 
tirely confined to the margin. On the external portion of the 
head of the tibia, the cartilage was absorbed to a greater extent. 
The bones possessed their natural structure and hardness. The 



54 ON MORBID CHANGE OP STRUCTURE 

cavity of the joint contained matter, and the sinuses communi- " 
cated with it. 

CASE XX. 

Michael Purcel, sixteen years of age, was admitted into St. 
George's Hospital, on the 10th of July, 1811, on account of a 
disease in the right knee. 

He said that, in the summer of 1807, he had received a blow 
on the inside of the joint. Some time afterwards a swelling 
formed and burst, and some fluid was discharged. In about a 
week the orifice healed; a slight degree of stiffness only re- 
mained, and he was able to follow his usual occupations. He 
continued well till December, 1810, when the joint was observed 
to be increased in size. From this time the swelling increased, 
but with no other inconvenience than stiffness of the joint, and 
jf. slight degree of pain in walking. 

At the time of his admission into the hospital there was a 
large swelling of the knee, extending an inch or more up the 
anterior part of the thigh, under the extensor muscles. The 
swelling was more prominent in some parts than in others. It 
was soft and elastic, and gave to the hand an indistinct sensa- 
tion, as if it contained fluid. The leg was kept in a half-bent 
position, and was nearly immovable on the thigh. He had 
no pain, except on motion or pressure. 

On the 28th of November, an abscess burst on the outside of 
the joint, and discharged a small quantity of pus. After this 
other abscesses formed, and burst at various times. The 
swelling continued to increase. Amputation was performed on 
the 6th of April. 

On dissecting the amputated joint, all the ligaments were 
found in a natural state. The synovial membrane had pre- 
cisely the same appearance as in the last case. In some parts 
it was half an inch, in others more than an inch, in thickness. 
The cartilages were for the most part destroyed by ulce- 
ration, and carious* surfaces of bone were exposed. The ab- 

* In using the term caries, on this and on other occasions, I have consi- 
dered it as synonymous with ulceration: or, at least, as expressing that state 
in bones, which corresponds to ulceration in soft parts. Some confusion has 
been produced in pathological nomenclature in consequence of this term 
having been employed by some to express, not only bone which is ulcerated, 
but that whose surface has been exposed from other causes, 



OF THE SYNOVIAL MEMBRANE. 55 

scesses appeared to have formed in the substance of the syno- 
vial membrane, and did not communicate with the cavity of 
the joint, nor did the joint contain pus. 

CASE XXI. 

A boy, six years of age, was admitted into St. George's 
Hospital, in March, 1808, on account of a disease in one knee. 

The joint was larger than the natural size. The leg was 
bent at a right angle to the thigh, and admitted of no motion. 
The skin on the outside w T as ulcerated to a considerable extent. 
Various remedies having been employed without success, the 
limb was amputated on the 29th of April. On examining the 
joint, the synovial membrane was found to have undergone a 
morbid change of structure, similar to that in the preceding 
cases; but with this difference, that the pulpy substance into 
which it was converted projected into the joint, so as nearly to 
fill its cavity, and adhered to the cartilaginous surfaces. On 
making a longitudinal section of the joint, the cartilage covering 
the bones was seen, as a white line, about one-tenth of an inch 
in thickness, connected to the bone on one side, and having 
the pulpy substance adhering to it on the other. It was, there- 
fore, thinner than natural; but otherwise entire, except at the 
posterior part of one of the condyles of the femur, where it was 
destroyed by ulceration for a small extent. There were no 
distinct remains of the ligaments external to the joint, and only 
some small vestiges of the crucial ligaments and semilunar 
cartilages. 

CASE XXII. 

John Dillemore, thirteen years of age, was admitted into St. 
George's Hospital, in the summer of 1812, on account of a 
disease in one knee. At that time the joint was slightly 
swollen and stiff, so as to admit of only a very limited degree 
of motion. He was free from pain. The swelling was elastic, 
without any perceptible fluctuation of fluid. These symptoms 
had been coming on gradually about two years previous to his 
admission. At this time he remained in the hospital for up- 
wards of three months ; and a great number of remedies, which 
it is unnecessary to enumerate, were employed without the 
smallest benefit. 

On the 26th of January, 1814, he was re-admitted into the 



56 ON MORBID CHANGE OF STRUCTURE 

hospital. The affected knee was about two inches and a half 
in circumference more than the other. The swelling was 
elastic; it extended up the anterior and lower part of the thigh, 
as in cases of inflamed synovial membrane; but its form was 
less regular, being more prominent, and extending higher up 
on the outside than on the inside. The leg was kept in the 
half-bent position, and was perfectly immovable on the thigh. 
He was subject to occasional attacks of violent pain. He said, 
that the swelling had gradually increased from the period of his 
quitting the hospital, in 1812, but that he had not been subject 
to very severe pain till about six weeks previous to his re-ad- 
mission. On the 31st of January the limb w T as amputated. 

On examining the diseased joint, the synovial membrane 
was found converted into a pulpy substance of a light brown 
eolour, with red spots arising from vessels ramifying in it in- 
jected with their own blood, and intersected by very numerous 
membranous lines. On the outside of the joint, the diseased 
membrane was in some places nearly an inch in thickness. 
The membrane covering the cartilages in some parts was in a 
natural state; in other parts, it had undergone the same morbid 
change of structure as elsewhere. The cartilages w r ere ulce- 
rated in spots. There was about half an ounce of pus in the 
cavity of the joint; and there were two or three abscesses in the 
substance of the synovial membrane, not communicating with 
the joint, containing in all about the same quantity of purulent 
matter. 

CASE XXIII. 

William Hine, twenty-three years of age, was admitted into 
St. George's Hospital on the 12th of December, 1814, on ac- 
count of a complaint in one of his knees. He said that, in the 
summer of 1812, he first observed a slight degree of stiffness 
and swelling of the joint, unattended by pain. At first the 
swelling was confined to the inside, but it gradually extended 
itself over the whole circumference of the joint. The stiffness 
and swelling slowly, but uniformly, increased, and about the 
end of the year 1813 he began to experience considerable pain. 

At the time of his admission, the knee was much swollen; 
the swelling was irregular, and most prominent on the inside ; 
it was soft and elastic, without the fluctuation of fluid. The 
patient complained of constant, deep-seated, gnawing pain, 



OF THE SYNOVIAL MEMBRANE. 57 

which disturbed his sleep. He had a slight degree of hectic 
fever. On the 16th of December the limb was amputated. 

On dissecting the amputated joint, the synovial membrane 
was found to have undergone the same morbid alteration of 
structure as in the last case. The cartilages were slightly ul- 
cerated in a few spots. 

CASE XXIV. 

James Gould, sixty-five years of age, was admitted into St. 
George's Hospital, in May, 1S14. One knee was swollen and 
stiff, admitting of scarcely any motion. The swelling was 
elastic. He complained of severe pain in the joint. Near the 
ligament of the patella was the orifice of a sinus communicating 
with the articular cavity, and discharging a very small quantity 
of pus. No clear history could be procured of the disease in 
its earlier stages; but it appeared that he had been subject to 
repeated attacks of inflammation of the synovial membrane. 

The limb was amputated on the 23d of May. 

On dissection, the ligaments, bones, cartilages, and that por- 
tion of the synovial membrane which is reflected over the car- 
tilages, were found to be in a natural state; but the synovial 
membrane in other parts had undergone the same morbid alte- 
ration of structure as in the preceding cases. 



These cases furnish examples of the same disease in different 
stages of its progress. The morbid action evidently originates 
in the synovial membrane, which loses its natural organization, 
and becomes converted into a thick pulpy substance, of a light- 
brown, and sometimes of a reddish-brown colour, intersected 
by white membranous lines. As the disease advances, it in- 
volves all the parts of which the joint is composed, producing 
ulceration of the cartilages, caries of the bones, wasting of the 
ligaments, and abscesses in different places. 

I have already remarked, that this disease is peculiar to the 
synovial membranes; at least, that I have never met with it in 
any other part of the body; but it belongs to the same order 
with tubercles of the lungs, scirrhus of the breast, the medul- 
lary sarcoma or fungus hasmatodes of the testicle, and nume- 
rous other diseases, in which the natural structure of the af- 
fected organ is destroyed, and a new and different structure is 
t 



58 ON MORBID CHANGE OF STRUCTURE 

added in its place. To these also it bears a near resemblance 
in its progress. Thus, tubercles of the lungs, in the first in- 
stance, occupy the vesicular and interlobular substance ; but ul- 
timately they inflame and ulcerate; abscesses form in them; 
and then the pleura, the bronchia, and other contiguous parts, 
become affected. Similar circumstances mark the progress of 
other maladies of the same description. 

The cases which have been related are not the only ones in 
which I have had the opportunity of tracing the same morbid 
appearances. I have also met with several others, in which the 
similarity of the history and symptoms, and the resemblance in 
the form and elasticity of the tumour, indicated the disease to 
be of the same nature, although I was not able to verify the 
fact by dissection. In every case, in which I have had it in 
my power to watch its progress, the complaint has advanced 
slowly, and sometimes has remained in an indolent state during 
a very long period: but ultimately it has always terminated in 
the destruction of the joint. 

It is a remarkable circumstance, that this affection of the sy- 
novial membrane is rarely met with except in the knee. I have 
never known an instance of it in the hip or shoulder.* It is 
probable that the influence of the external cold may operate as 
one of the causes by which the disease is produced, and this 
may explain why it occurs frequently in the knee, and seldom 
in deep-seated articulations.^ 

It is evident from the history of cases in which a part of the 
living body has assumed a new and morbid structure, that this 
alteration seldom takes place except by slow degrees; and it 
would add much to the interest and utility of researches in mor- 
bid anatomy if it were more frequently attempted to ascertain, 
what is the first change in the organization of the affected part 

* My friend, Mr. Hodgson, surgeon to the hospital at Birmingham, informs 
me that he has met with one example of it in the ankle, and another in one 
of the joints of a finger. 

t The account of the fun gus articuli, which has been given by some Ger- 
man writers, appears to have been drawn, partly, from cases of disease de- 
scribed in this chapter, partly, from cases of inflammation of the synovial 
membrane. Mr. Russel seems to have taken his history of the pathology of 
white-swelling in great measure from cases similar to those which have been 
related; but we must observe, that the term white-swelling has been applied, 
almost indiscriminately, to all the affections to which the joints are liable, and 
by no means confined to that under our present consideration. 



OF THE SYNOVIAL MEMBRANE. 59 

which disease producevS, and from thence to trace the gradual 
progress of the other changes which take place, until the de- 
struction of the natural organization is completed. Whether 
the following case is to be considered as of the same kind with 
those already recorded, but in an earlier stage of the disease, 
cannot at present be determined ; but it appears not improbable 
that it is so; and I shall venture to relate it, in this place, in 
the expectation that it may, at any rate, be of some service in 
assisting the investigations of future inquirers. 

CASE XXV. 

Belton, a boy eleven years of age, was admitted into 



St George's Hospital, in August, 1810, on account of a disease 
in one knee. 

There was but little pain in the joint: it was slightly en- 
larged, admitted of some motion, but not of complete flexion 
and extension. His parents said that the. disease had begun 
about a year and a half before his admission into the hospital, 
that it had increased very slowly; and that he had never suf- 
fered from it any serious distress. Various remedies were em- 
ployed without benefit; and in a short time his friends took him 
out of the hospital. A few weeks afterwards he died, in con- 
sequence of an accumulation of water in the ventricles of the 
brain. 

I obtained permission to examine the body. 

The synovial membrane of the affected knee externally had 
its natural appearance. Internally it was lined by a straw-co- 
loured gelatinous substance, so intimately adhering to it, that it 
could not be detached, except by an artificial separation. The 
synovial membrane was incrusted in this manner every where 
except on the cartilaginous surfaces. The gelatinous substance 
in general appeared about one-eighth of an inch in thickness; 
but in some parts, near the borders of the cartilages, it was much- 
thicker, so as to project considerably into the cavity of the 
joint. In a few places, towards the margin of the articulating 
surfaces, the cartilage had begun to ulcerate; in some of these it 
was entirely absorbed, so that the bone was exposed; but, for 
the most part, there was only an irregular ulcerated surface to- 
wards the cavity of the joint: the remaining portion of the 
cartilage being entire, and having its natural adhesion to the 
bone. 



60 ON MORBID CHANGE OF STRUCTURE 

The synovial membrane itself bore no marks of inflamma- 
tion. In the substance with which it was lined, some vessels 
were observed ramifying, beautifully injected with their own 
blood; but these were few in number, and only in certain 
parts. This substance differed in appearance from the coagu- 
lated lymph which is found on the surface of an inflamed mem- 
brane; and we may presume, therefore, that the effusion of it 
was the result, not of inflammation, but of some other morbid 
action. 



SECTION II. 

ON THE SYMPTOMS OF THIS DISEASE. 

This disease generally takes place in persons who are not 
much above the age of puberty. I do not recollect more than 
one instance of it having occurred after the middle period of 
life. In general it can be traced to no evident cause, but oc- 
casionally it is the consequence of repeated attacks of inflam- 
mation. In this respect it resembles other diseases of the same 
order. Inflammation of the lungs may lay the foundation of 
tubercles, and inflammation of the breast may occasion the 
growth of a scirrhous tumour. Where I have had an oppor- 
tunity of examining the morbid appearances after amputation, 
I have always found the whole, or nearly the whole, of the sy- 
novial membrane affected by the disease; but it is probable, 
that if the examinations were made at an earlier period, 
we should often find the morbid change originating in some 
one point. At least this is in conformity to what we find in 
other maladies, which correspond to this in their nature; and 
in one instance, in a girl who laboured under this affection, and 
who died of an attack of fever, I found one-half of the syno- 
vial membrane altered in structure, and the other half retaining 
its natural appearance. 

In the origin of this disease, there is a slight degree of stiff- 
ness, and tumefaction, without pain, and producing only the 
most trifling inconvenience. These symptoms gradually in- 
crease. In the greater number of cases, the joint at last scarce- 
ly admits of the smallest motion; but, in a few cases, it always 



OP THE SYNOVIAL MEMBRANE- 61 

retains a certain degree of mobility. The form of the swelling 
bears some resemblance to that in cases of inflammation of the 
synovial membrane, but it is less regular. The swelling is soft 
and elastic, and gives to the hand a sensation as if it contained 
fluid. If only one hand be employed in making the examina- 
tion, the deception may be complete, and the most experienced 
surgeon may be led to suppose that there is fluid in the joint, 
when there is none : but if both hands be employed, one on 
each side, the absence of fluid is distinguished by the want of 
fluctuation. 

The patient experiences little or no pain, until abscesses be- 
gin to form, and the cartilages ulcerate; and even then the pain 
is in many instances not so severe as where the ulceration of 
the cartilages occurs as a primary disease; and the abscesses heal 
more readily, and discharge a smaller quantity of pus, than in 
cases of this last description. At this period the patient be- 
comes affected with hectic fever; loses his flesh, and gradually 
sinks, unless the limb be removed by an operation. 

The progress of this disease varies in different cases. In gene- 
ral, one or two years elapse before it reaches its most advanced 
stage; but sometimes the period is much longer; and occasion- 
ally it becomes indolent, so that it remains during many months 
without any sensible alteration. In like manner, tubercles of 
the lungs, or scirrhus of the breast, in some instances, remain 
in an inactive state for several months, or even for one or two 
years. 

The diagnosis of this disease is seldom difficult. The gra^ 
dual progress of the enlargement and stiffness of the joint with- 
out pain, and the soft elastic swelling without fluctuation, in 
the majority of cases, enable us to distinguish it readily from 
all the other morbid affections to which the joints are liable. 

The cases with which those of this disease are most liable to 
be confounded, are those of chronic inflammation of the syno- 
vial membrane. 

1st, When the synovial membrane has undergone a morbid 
change of structure, it occasionally happens that a preternatural 
secretion of fluid takes place at the same time from its inner 
surface; and the joint becomes distended, not with synovia, 
but with a turbid serum, having flakes of coagulated lymph 
floating in it, which causes the tumour to present nearly the 

6* 



62 ON MORBID CHANGE OF STRUCTURE. 

same external characters as where the synovial membrane is 
inflamed. But here the swelling will not yield to that treat- 
ment, under which it would be speedily reduced if it depended 
on simple inflammation; and attention to this circumstance, 
joined with an accurate previous history, will enable us to re- 
cognise the real nature of the disease. 

2dly, When the synovial membrane, after inflammation has 
subsided, has been left in a thickened state, and coagulated 
lymph has been effused into the articular cavity, the tumour, 
in some instances, a good deal resembles the tumour which 
occurs in cases of this disease; so much so, that it will be very 
difficult to give a correct opinion, merely from observing the 
present appearance and condition of the joint. The surgeon 
must, under these circumstances, in great measure form his 
judgment from the account which he receives of the origin and 
early symptoms of the complaint; or (when an accurate state- 
ment cannot be procured) by waiting to observe its future 
progress. 



SECTION III. 

ON THE TREATMENT. 

When a part is swollen and rigid in consequence of inflam- 
mation, the swelling and rigidity may often be dispersed; but 
I know of no instance in which an organ having completely 
lost its natural structure is capable of having that structure re- 
stored. Physicians and surgeons have been employed during 
successive ages, in endeavouring to (Jiscover a cure for tuber- 
cles of the lungs, and cancer of the breast, and the result of 
their labour is only to prove that these diseases are incurable. 
Analogy, therefore, would not lead us to be sanguine as to the 
discovery of a remedy for this affection of the synovial mem- 
brane, and experience demonstrates that it is equally incurable 
with other maladies of the same order. It would be needless for 
me to occupy the time of my readers by a detail of the various 
remedies which I have tried, or seen tried by others, in cases of 
this description; since the general result of these trials was 



ON THE ULCERATION OF THE ARTICULAR CARTILAGES. 63 

only to lead to the above conclusion. By means of rest and 
cold lotions, the progress of the disease may be somewhat 
checked, as the suppuration of tuberculated lungs may be re- 
tarded by occasional bleeding, and a milder climate. Where 
there is considerable pain in consequence of the cartilages having 
begun to ulcerate, some benefit is derived from the use of warm 
fomentations and poultices. But no method, with which I am 
acquainted, is capable of doing more than somewhat checking 
the progress, and somewhat relieving the symptoms of the 
complaint. In every case of which 1 have had an opportunity 
of seeing the termination, the ulceration of the cartilages, the 
formation of abscesses in the cavity of the joint, and the conse- 
sequent disturbance of the patient's general health, have ulti- 
mately rendered the amputation of the limb necessary, in or- 
der to preserve the patient's life. At this period, therefore, 
the surgeon is called upon to recommend and urge an operation; 
but at an earlier period, it is a matter of choice with the pa- 
tient, whether he will live with the incumbrance of a useless 
limb, till the advanced stage of the disease renders its removal 
indispensable, or whether he will submit to the loss of it, be- 
fore the absolute necessity for losing it exists. 



CHAPTER IV. 



ON THE ULCERATION OF THE ARTICULAR CARTILAGES. 



SECTION I. 

PATHOLOGICAL OBSERVATIONS. 

It has been taught by some anatomists, that the articular 
cartilages are not endowed with vascularity; and that, when 
there is an appearance of their having been destroyed by ulce- 
ration, this must really have been effected, not by the action of 
vessels in the cartilages themselves, but by that of the vessels 



64 ON THE ULCERATION 

of the other parts with which they are connected, or with 
which they come in contact. Various circumstances, however, 
seem to be in contradiction to these opinions. 

Up to the period of growth being concluded, we must sup- 
pose the articular cartilages to be vascular, otherwise we cannot 
account for the changes of bulk and figure which mark their 
progress towards complete development. In the child, canals 
or sinuses may be seen ramifying through their substance 
containing blood, and manifestly intended to answer the pur- 
poses, though not constructed with the distinct tunic3, of or- 
dinary blood-vessels. 

In the adult person these canals for the distribution of blood 
are not perceptible. This proves that they are very minute, 
but not that they are altogether wanting. 1. In the transpa- 
rent cornea of the eye, no vascular structure can be detected 
under ordinary circumstances; but the existence of vessels in 
the cornea is proved by the changes which it undergoes in dis- 
ease; and when it is inflamed, such vessels become distinctly 
visible, injected with red blood. So we meet with occasional, 
though rare instances, of vessels containing red blood extend- 
ing from a diseased bone into the cartilage covering it. Cases, 
in which this appearance was observed, will be mentioned in 
the next chapter, and similar appearances have been noticed 
and described by Mr. Maj^o.* 2. The cartilages of the joints 
are subject to the constant and the powerful operation of fric- 
tion, yet they are not affected by it. They continue as thick 
and as perfect in those who are unremittingly engaged in bodily 
exercise, as in the most inactive persons. The cartilages of 
the knee and ankle are exposed to friction at least as much as 
the hard enamel and ivory of the teeth; yet we often see per- 
sons in whom the latter are much worn away, while the for- 
mer remain entire. These circumstances cannot be explained, 
unless we admit the cartilages to possess a power of reparation; 
and this must be supposed to depend,' as in other textures, on 
the action of blood-vessels modified by that of the absorbents. 
3. We find occasionally some portion of the cartilage covering 
the articular extremity of a bone altered from its natural or- 
ganization, converted into a number of fibres resembling liga- 

* Mayo on Ulceration of the Cartilages of the Joints; in the Medico- 
Chiruigical Transactions, vol. xix. p. 63, 61 



OF THE ARTICULAR CARTILAGES. 65 

ment, each of which is connected by one extremity to the 
bone, while the other is loose towards the cavity of the joint. 
Here is a morbid alteration of structure, the occurrence of 
which seems to indicate that there must be such a vascular ap- 
paratus entering into the formation of cartilage as enables new 
materials to be deposited, and old materials to be absorbed, and 
without which morbid alterations of structure do not take place 
in other parts of the body.* 

In some of the cases related in the former chapters, the car- 
tilage covering the articular cartilage had been removed for 
some extent on the surface towards the cavity of the joint, while 
that portion of it which was connected to the bone remained 
entire, and retained its natural structure. In the two follow- 
ing cases, the same thing was observed to a very great extent; 
and this superficial abrasion had taken place in many parts, 
in which cartilage was in contact with cartilage, and where, 
therefore, it was impossible to attribute it to the operation of 
vessels belonging to any of the neighbouring textures. 

CASE XXVI. 

A boy, twelve years of age, on the 28th of June, 1809, fell 
from a height, and pitched on one of his knees. When he was 
brought to the hospital, he was found to have a compound frac- 
ture of the femur. For some days he appeared to go on well; 
but afterwards an abscess formed in the thigh, extending as high 
as the nates; and he sunk and died on the 21st of July. On 
examining the knee-joint after death, the cartilage covering the 
condyles of the femur, and that covering the head of the tibia, 
were found, in some parts, entirely absorbed, so that the bone 
was exposed; while in other parts it was absorbed on the sur- 
face towards the cavity of the joint, the layer of it next to the 
bone retaining its natural adhesion, and its natural structure. 
The cartilage, in these parts, was formed into grooves, having 
an appearance as if the greater portion of its substance had been 
removed with a chisel. There was no purulent, nor other effu- 
sion, into the cavity of the joint. 

* For farther observations relating to this pathological question, see the 
note at the end of this volume. 



66 ON THE ULCERATION 



CASE XXVII. 



A middle-aged man met with an injury of the knee, which 
was followed by inflammation and suppuration, and he died in 
St. George's Hospital on the 30th of August, 1809. 

On examining the joint after death, the cartilage covering the 
condyles of the femur, and the head of the tibia, was found en- 
tirely destroyed towards the circumference, so that the bone 
was exposed. Elsewhere, only a thin layer of cartilage re- 
mained; but this had its ordinary texture, and adhered as firmly 
as usual to the bone. 



I conceive that the foregoing cases, and the other facts which 
have been stated, are sufficient to prove that the articular car- 
tilages may be absorbed or ulcerated from the action of their 
own vessels, and that the ulceration may begin, and frequently 
does begin, on that surface which is towards the articular cavity. 
At the same time, it is to be observed, that in many instances 
the ulceration begins in another situation; and that I have fre- 
quently seen the cartilage abraded where it had been in con- 
tact with the bone; while on the surface, towards the cavity of 
the joint, it remained smooth and perfect. Under these cir- 
cumstances, the space formed by the absorption of the cartilage 
becomes filled up by a vascular substance, resembling granula- 
tions, and uniting the bone and cartilage to each other. 

In whatever way the ulceration of the articular cartilage is 
produced, there is this remarkable difference between it and the 
ulceration of soft parts; suppuration seldom takes place while 
the ulcer of the cartilages is small, and often the disease pro- 
ceeds so far as to cause caries of the bones to a great extent, 
without matter being formed in the joint. This circumstance 
is deserving of notice. It has long been established, that sup- 
puration may take place without ulceration; and it appears that 
in this instance ulceration occurs without the formation of pus. 



Ulceration of the articular cartilages may arise under various 
circumstances: — 

1st, It may be the consequence of disease originating in the 
neighbouring soft parts, especially of inflammation of the sy- 



OF THE ARTICULAR CARTILAGES. 67 

novial membrane; examples of which may be found among the 
cases related in the preceding chapters. 

2dly, It may depend on a morbid condition of the cartilage 
itself; or, 

3dly, On a chronic inflammation of the surface or substance 
of the bone with which it is connected. 

4thly, It may be the result of a peculiar alteration in the con* 
dition of the cancellous structure of the bones, which is met 
with in young scrofulous persons. 

This last form of the disease requires to be considered sepa- 
rately, and will constitute the subject of the next chapter. The 
observations, which I have to offer at present, will relate to ul- 
ceration of the cartilages occurring under other circumstances, 
but especially to those cases, in which the disease has originated, 
either in the cartilage itself, or in the surface of bone with which 
it is connected. In practice I do not undertake to distinguish 
these two orders of cases from each other, and according to my 
experience it is often difficult, and sometimes impossible, to do 
so even in our dissections. 

CASE XXVIIL 

In examining a body brought into the dissecting-room in 
Windmill Street, I found the cartilage in a diseased state, in 
the joints of both hips, of one of the knees, and of both el- 
bows. In some spots, the cartilages of these joints were alto- 
gether destroyed by ulceration, and carious surfaces of bone 
were exposed; in others, the cartilage was not completely ab- 
sorbed, but it had the appearance of fibres, which were con- 
nected at one extremity to the bone, while the other extremity 
was loose towards the cavity of the joint, and having no lateral 
connexion with each other. The intervertebral cartilages con- 
necting the bodies of some of the dorsal vertebras were also in 
a diseased state. They retained the usual appearance of con- 
centric layers towards the circumference; but in the centre, in- 
stead of the white semi-fluid substance, which is met with un- 
der ordinary circumstances, they were found to be of a brown 
colour, of a solid and somewhat brittle texture, composed of se- 
veral portions, having a very slight adhesion to each other. 
The ligaments, the synovial membranes, and the bones, were 
all in a natural state, except that the latter were occasionally 



t38 ON THE ULCERATION 

carious, in consequence of the absorption of the cartilage; the 
caries being unattended by the formation of matter. 

In this case the original disease appears to have been a mor- 
bid state, and subsequent ulceration of the cartilages. It shows 
that where the disposition to it exists, the destruction of the 
cartilage may take place in several joints at the same time; and 
I have observed the same thing in other instances. 

The conversion of the cartilage into a soft fibrous structure 
has been already noticed. I am disposed to believe that it is 
the frequent, though not the constant, forerunner of ulceration. 
In a woman, who died a week after a severe contusion of the 
hip, the cartilage of the head of the femur was found in some 
parts entirely absorbed, in others .having a fibrous appearance, 
similar to what has been described; and I have noticed the 
same circumstances in other cases, sometimes connected with, 
and sometimes independent of, local injury. 

CASE XXIX. 

A girl, seven years of age, was admitted into St. George's 
Hospital, in May, 1809, on account of a complaint in the left 
hip. She had pain in the knee, the limb was shorter than is 
natural, and the nates were w T asted and flattened. An issue 
was made with caustic, behind the great trochanter. Soon after 
her admission an abscess burst near the crista of the ilium. The 
disease in the hip appeared to be considerably relieved; but, on 
the 1st of August, she died of an accidental attack of erysipelas. 

On inspecting the body, the glutaei muscles of the left side 
were found wasted, and of a dark colour. A sinus extended 
from the external orifice of the abscess through the soft parts, 
and communicated with the hip-joint, by an ulcerated opening 
in the margin of the acetabulum. 

There were no remains of cartilage on the surface of the ace- 
tabulum. The exposed bone was in a carious state, and of a 
dark colour, and the cavity of the acetabulum was rendered 
deeper and wider than is usual. The greater part of the car- 
tilage was destroyed on the head of the femur, and the small 
portion of it, which remained, was readily separated from the 
bone. This circumstance is often met with, where cartilage is 
undergoing the process of ulceration. 

The capsular ligament was somewhat thicker than under an- 




OP THE ARTICULAR CARTILAGES. 69 

tural circumstances, and more closely connected with the sur- 
rounding parts. There were no remains of the round ligament. 

In the anterior part of the joint, a quantity of organized soft 
substance, resembling that of adhesions, was interposed between 
the head of the femur and the acetabulum, and behind this was 
a collection of dark-coloured pus. From these two causes the 
head of the femur had been separated from the os innominatum, 
and pushed outwards, and it had afterwards been drawn up- 
wards by the action of the muscles, so that it was lodged on the 
superior part of the bony margin of the acetabulum. The sy- 
novial membrane was of a dark colour, but not otherwise dis- 
eased. 

On examining the hip of the opposite side, I found the soft 
parts external to it, the capsular ligament, synovial membrane, 
and fatty substance of the joint, having no appearance of dis- 
ease. The cavity of the joint contained about a drachm of dark- 
coloured pus. The cartilage was absorbed from about one-third 
of the surface of the acetabulum. The exposed bone in most 
parts presented a uniform compact surface, but in two places it 
was in a state of superficial caries. In some parts of the head 
of the femur, the cartilage had a fibrous appearance, similar to 
what has been already described; in other parts it was entirely 
absorbed, and a carious surface of bone was exposed: and else- 
where it was in a natural state. The round ligament was rup- 
tured by a very slight degree of force, which seemed to arise 
from the. cartilage having been destroyed round its insertion 
into the acetabulum. 

The bones in the neighbourhood of the carious surfaces of 
the left hip were of a darker colour than usual; but no such 
appearance was observed in the bones of the other hip, which 
were in all respects in a healthy state. 

CASE XXX. 

John Catnack, forty-four years of age, was admitted into St. 
George's Hospital on the 29th of September, 1813, with pains in 
the lower limb of the right side, extending from the hip to the 
knee, and resembling the pains of rheumatism. He attributed 
these pains to his having caught cold about a month before his 
admission. He laboured also under a complaint of his bowels, of 
which he died on the 4th of December. On dissection, no pre- 
7 



70 ON THE ULCERATION 

ternatural appearances were discovered, except in the right hip. 
The capsular ligament and synovial membrane were in a na- 
tural state. The cartilages covering the head of the femur, and 
lining the bottom of the acetabulum, had been destroyed by ul- 
ceration, for about one half of their extent; and wherever the 
cartilage was destroyed, an ulcerated surface of bone was ex- 
posed. The round ligament was readily torn in consequence 
of ulceration having extended to it at the part where it was in- 
serted into the acetabulum. The bones possessed their natural 
texture and hardness. There was no pus in the joint. It 
was observed, that the ulcerated surface of the acetabulum cor- 
responded to that of th£ femur, these surfaces being exactly in 
contact, in the position in which the patient had remained since 
his admission into the hospital. 

CASE XXXI. 

William Bridges, twenty-one years of age, was admitted into 
St George's Hospital, on the 28th of November, 1810. He 
gave the following account of his complaint:— About the mid- 
dle of the May preceding, he first experienced a pain in the 
right knee, which was aggravated by walking. At the end of 
a month, the pain became so severe that he was under the ne- 
cessity of being confined to his bed. He had slight pain in the 
hip; but that in the knee was intense, keeping him awake at 
night. An abscess formed, which, in the September following 
burst on the inside of the thigh. 

At the time of his admission, the nates were wasted and flat- 
tened; the limb on the affected side appeared to be an inch and 
a half longer than the other; there was a large abscess in the 
posterior part of the' thigh. He was emaciated, and laboured 
under a hectic fever. An issue was made with caustic, behind 
the great trochanter of the femur, and afterwards a second issue 
was made in the same manner on the anterior edge of the ten- 
sor vagina femoris muscle. Under this treatment, he expe- 
rienced for a time great relief, notwithstanding that several ab- 
scesses formed and burst in different parts of the thigh. He 
became free from pain; regained his flesh; the hectic fever 
abated; and the discharge from the abscesses was much lessened. 
The limb now appeared to be shorter than the other. He con- 
tinued to mend till the middle of February, 1811. At this pe- 



OF THE ARTICULAR CARTILAGES. 71 

riod the former bad symptoms began to return. He was af- 
fected with a constant diarrhoea, and profuse perspirations, and 
he died on the 26th of March following. 

On inspecting the body, the glutaei muscles were found 
wasted and shrunk, and in many parts their texture was de- 
stroyed by the abscesses, which communicated with the cavity 
of the joint bf two ulcerated openings, one on the anterior, and 
the other on the posterior part. The abscesses formed several 
sinuses in the neighbourhood of the joint, and the capsular liga- 
ment was in consequence connected to, and in some measure 
blended with, the other soft parts. 

The joint contained purulent matter. The synovial mem- 
brane was darker than natural, but otherwise had the ordinary 
appearance. There were no remains of the round ligament. 
The cartilages were every where absorbed, and the exposed sur- 
faces of bone were in a carious state. The head of the femur 
was reduced to about two-thirds of its original size; and the 
acetabulum was rendered deeper and wider, nearly in the same 
proportion. At the bottom of the acetabulum there was an ul- 
cerated opening, just large enough to admit a common probe, 
communicating with an abscess within the pelvis. The carious 
surfaces of the bones had the same dark colour and fetid smell 
as in many other cases of caries; but otherwise they did not 
differ from the healthy bones. 

CASE XXXII. 

Jemima Holloway, about twenty-three years of age, was ad- 
mitted into St. George's Hospital on the 30th of March, 1814, 
on account of a disease of the right hip. There was a large ab- 
scess in the neighbourhood of the hip, and the nates were 
wasted and flattened. She said that the disease had been going 
on for some years. On the 6th of June following her admission, 
she died. 

On dissection, the glutaei muscles were found wasted and 
flabby, and of a pale colour. 

There was a large abscess of the nates communicating with 
the hip, by means of an opening in the posterior part of the cap- 
sular ligament and synovial membrane. In other respects the 
synovial membrane and capsular ligament were in a perfectly 
natural state. 



72 ON THE ULCERATION 

The cartilages covering the head of the femur and lining the 
bottom of the acetabulum were destroyed by ulceration. The 
ulceration had extended to the bones, so that the head of the 
femur was not more than half, and the acetabulum was double, 
the usual size. The bones possessed their natural texture and 
hardness. There was an ulcerated opening at the bottom of 
the acetabulum, communicating with the inside &f the pelvis. 

CASE XXXIII. 

Phoebe Harper, twenty-four years of age, was admitted into 
St. George's Hospital on the 29th of August, 1825. 

About two months previous to her admission she had been 
seized, while employed in hay-making, with an excruciating 
pain in the lower limb of the left side. 

It subsided sufficiently to allow her to walk home; but on the 
following day it returned, and it was now referred particularly 
to the groin. Leeches, blisters, &c. were applied, but the pain 
continued very severe. 

At the time of her being admitted into the hospital she was 
unable to move the limb: the foot was turned outwards; and 
every attempt to press the head of the femur against the surface 
of the acetabulum, as well as all pressure in the neighbourhood 
of the hip-joint, occasioned violent pain, so as to make the pa- 
tient scream. The whole limb was hotter than natural; and 
the pulse beat between 90 and 100 in a minute. 

Altogether the disturbance of the constitution was greater 
than might be expected from such a local complaint. 

October 24th, the patient died. On dissection, it was found 
that no effusion, either of serum, or lymph, or pus, had taken 
place into the cavity of the hip-joint. 

The synovial membrane was somewhat more vascular than 
usual, but the increased vascularity seemed scarcely to amount 
to inflammation. The cartilage covering the head of the femur 
had been destroyed by ulceration for more than half its extent; 
so as to expose the cancellous structure of the bone. The re- 
maining portion of the cartilage covering the head of the femur 
was thinner than natural: but this was more observable in some 
parts than in others. Every where the loss of substance ap- 
peared to be on the surface towards the cavity of the joint; the 
layer of cartilage towards the bone being unaltered, except in 



OF THE ARTICULAR CARTILAGES. 73 

one spot, where it was destroyed by ulceration to a very small 
extent. 

The cartilage of the acetabulum was entirely destroyed, so 
that every where a carious surface of bone was exposed. 

There were no remains of the round ligament. 

The synovial membrane on one part of the neck of the femur 
was destroyed by ulceration; and here also a carious surface of 
bone was exposed. 

The bones themselves had their natural structure and hard- 
ness, not differing from healthy bones, except on the carious or 
ulcerated surfaces. 



I could add to the foregoing an account of the dissection of 
several other cases, in which the hip was affected with the same 
disease; but, in doing so, I should only occupy the reader's at- 
tention unnecessarily. It will be sufficient to observe that, — 

1. In the most advanced stage of the disease, none of the parts 
entering into the composition of the joint retain their natural 
structure. The soft parts are blended into a confused mass. 
Sometimes the head of the femur is completely destroyed, and 
there remains only the neck, or a portion of the neck, of that 
bone. Often the projecting margin of the acetabulum is en- 
tirely absorbed; so that, instead of a cavity, there is a broad ca- 
rious surface of the os innominatum. In a few instances, a por- 
tion of the carious bone is found dead, and undergoing the pro- 
cess of exfoliation, or having already exfoliated into the cavity 
of the joint. 

2. In whatever period of the disease the examination is made, 
the cartilages are found in a state of ulceration; but the morbid 
affections of the soft parts and bones vary very much: nor are 
they much altered from their natural state, except in the most 
advanced stage of the malady. 

From these circumstances, and from the appearances in se- 
veral of the cases which have been related, in which the dis- 
ease was found in its incipient stage, and wholly confined to the 
cartilages and bony surfaces with which the cartilages are in 
contact, we may conclude that, in a large proportion of cases of 
caries of the hip, these are the parts primarily affected, and the 
following may be stated to be the progress of the disease: — 

7* 



74 ON THE ULCERATION 

1. Ulceration takes place in the cartilages; generally in that 
of the acetabulum first, and in that of the head of the femur af- 
terwards: sometimes it begins in both at the same time. 

2. The ulceration extends to the bones, which become carious; 
the head of the femur is diminished in size, and the acetabulum 
is rendered deeper and wider. 

3. Abscess forms in the joint; which after some time makes 
its way, by ulceration, through the synovial membrane and cap- 
sular ligament, into the thigh or nates, or even through the bot- 
tom of the acetabulum, into the pelvis. 1 have met with some 
cases in which an abscess connected with a diseased hip had 
burst into the rectum. 

4. In consequence of the abscess,,the synovial membrane and 
capsular ligament become inflamed and thickened. The mus- 
cles are altered in structure; sinuses are formed in various parts; 
and, at last, all the soft parts are blended together into one con- 
fused mass, resembling the parietes of an ordinary abscess. 

In giving this statement, it is not my intention to assert that 
the hip is not liable to other morbid affections. I have in a 
former part of this work described the symptoms produced by 
inflammation of the synovial membrane of this joint. In the 
next chapter 1 shall point out another order of cases, in which 
the hip is affected in consequence of a scrofulous disease ori- 
ginating in the bones themselves; but still the conclusion re- 
mains that, in a large proportion of those cases to which the 
name of "diseased hip" has been usually applied, the ulceration 
of the cartilages is the primary affection, and the other parts in 
and near the joint become affected only in a secondary manner. 

As, from the peculiar situation and connexions of the hip, 
diseases of this part are attended with particularly serious con- 
sequences, I trust that the foregoing account will not be con- 
sidered as given too much in detail, especially as it will pre- 
vent the necessity of entering with much minuteness into the 
history of the ulceration of the cartilages of other joints, in 
which the progress of the disease, allowance being made for 
the difference of structure and situation, is the same as in the 
hip. 

CASE XXXIV. 

David Martin, twenty-six years of age, was admitted into 
St. George's Hospital, on the 25th of July, 1810, on account 



Or THE ARTICULAR CARTILAGES. 75 

of a disease in his right knee. He attributed it to a blow, 
which he had received some years previous; but he said, that 
the symptoms had all been much aggravated within the last 
six months. At the time of his admission into the hospital, 
the knee had the appearance of being swollen; but, on exami- 
nation, this was found to arise from the wasting of the muscles, 
rather than from actual enlargement. The leg was fixed, or 
nearly so, in the half-bent position. The condyles of the fe- 
mur projected beyond the head of the tibia. He complained 
of pain, which was particularly severe at night. An issue was 
made with caustic on each side of the patella; but the symp- 
toms were not relieved, and an abscess burst on the outside of 
the joint, discharging a large quantity of matter. 

Soon after his admission, he experienced, for the first time, 
severe pain in the other knee; but this was unattended by 
swelling, or any alteration in the form of the joint, and the leg 
admitted of complete extension and flexion on the thigh. The 
pain continued, but no swelling ever took place. 

In the beginning of September, he was seized with an acci- 
dental attack of erysipelas. Abscesses formed in different 
parts of the leg and thigh; and he gradually sank, and died on 
the 7th of November. 

On inspecting the body, the right leg was found bent so as 
to form a right angle with the thigh. The head of the tibia 
had been drawn towards the ham by the action of the flexor 
muscles, so that the condyles of the femur were unusually pro- 
tuberant. The lateral ligaments were in a natural state. There 
were no remains of the crucial ligaments, or semi-lunar carti- 
lages. The cartilages of the tibia, femur, and patella had en- 
tirely disappeared. The bones were carious on their exposed 
surfaces, but not otherwise diseased. The synovial membrane 
was free from all morbid appearances, except at the points of 
its attachment to the bones; where, in a few places, coagulated 
lymph had been effused on its surface. 

The left knee, externally, had its natural appearance with 
respect both to form and size. The leg admitted of complete 
flexion and extension. On dissection, the ligaments and syno- 
vial membrane were found in a perfectly healthy state; but 
about one-third of the cartilaginous surfaces of the tibia and 
femur was destroyed by ulceration, the ulceration having taken 



76 ON THE ULCERATION 

place principally, but not entirely, near the circumference* 
The cartilage of the patella and the semi-lunar cartilages were 
entire; but the latter, in some parts, were softer than usual. 
The bones were free from disease. There was no pus or 
other fluid in the joint. 

The dissection of this case, in which the ulceration of the 
cartilaginous surfaces was evidently the primary disease, ex- 
plains well the nature of, at least, many cases of that species of 
white-swelling, which some authors have described; in which 
there is long-continued jtnd severe pain in the joint, before any 
tumour is observable. 

CASE XXXV. 

William Bowles, eighteen years of age, was admitted into 
St. George's Hospital, on the 1st of December, 1810. He said 
that, about eleven months previous to his admission, he had 
been seized with pain in his right knee, which was so severe 
as to keep him frequently awake at night. Six weeks after 
the pain attacked him, the joint for the first time became 
swollen. He now applied to a practitioner; under whose treat- 
ment, joined with perfect rest, the pain and swelling subsided, 
so that he was able to walk about. In the September following, 
having returned to his usual occupations, and used the joint a 
good deal, the pain and swelling returned. 

At the time of his admission, the affected knee was about an 
inch and a half in circumference larger than the other. The 
swelling had the form of the articulating ends of the bones. 
The leg was half bent, and all attempts to give it motion gave 
great uneasiness. The pain which he experienced was great 
at all times, but particularly at night, when it very much dis- 
turbed his rest. 

Soon after his admission, an abscess was discovered on the 
outside of the knee, which burst in the beginning of February, 
and discharged a large quantity of matter. On the 18th of 
March, the limb was removed by amputation. 

On examining the joint, the greater part of the cartilaginous 
surfaces of the tibia, femur, and patella were found destroyed 
by ulceration. Where the cartilage was destroyed, the exposed 
bone was carious, and in some places covered by a thin layer 
of coagulated lymph; but in other respects the bone was free 



OF THE ARTICULAR CARTILAGES. 77 

from disease. There was scarcely any remains of the semi- 
lunar cartilages. The joint contained pus, and the abscess in 
the joint had made its way into the external parts, through an 
ulcerated opening in the synovial membrane. The synovial 
membrane was in a natural state, except that, in a few places, 
there was a thin layer of coagulated lymph on its surface, which 
evidently had been recently effused. The external lateral liga- 
ment was destroyed by the abscess; the other ligaments were 
entire. 

In this case, the principal disease observed in the dissection, 
was the ulcerated state of the cartilages. There was no affec- 
tion of the synovial membrane beyond what might be consi- 
dered as arising from the formation of pus in the joint, and the 
bursting of the abscess externally. Where inflammation of this 
membrane is the primary disease, swelling takes place often in 
a few hours, always within two or three days from the begin- 
ning of the attack; whereas, in this instance, the constant an- 
swer which the patient gave to the repeated inquiries made of 
him, was, that he had had violent pain for six weeks before the 
joint was observed to be enlarged. From all these circum- 
stances, we may conclude that, in this case, as well as in the 
last, the cartilages were the original seat of the disease, and that 
the morbid appearances observed in the soft parts were the 
consequence of the formation of the abscess in the joint. 

The same conclusion may be drawn respecting the cases 
which follow. 

CASE XXXVI. 

Mary Anderson, twenty-eight years of age, was admitted 
into St. George's Hospital, on the 6th of April, 1815. 

At this time, she complained of intense pain in the right 
knee, which was particularly severe at night, so as exceedingly 
to interrupt her rest. The pain was referred principally to the 
head of the tibia. There was a slight swelling of the joint, 
having the form of the articulating ends of the bones, and not 
giving to the hand the smallest sense of fluctuation. The leg 
admitted of being moved on the thigh, but all motion aggra- 
vated the pain. 

No more particular account of the previous history of the 
case could be procured than the following: — that she had la- 



78 ON THE ULCERATION 

boured under pains of the right knee for nearly six years, which 
had been occasionally relieved; and that, in the first instance, 
the pain had been unattended by swelling. 

Immediately on her admission, an issue was made with 
caustic, on each side of the patella. On the 9th of April the 
pain had very much abated. The issues were kept open by 
the occasional application of caustic; and the pains very soon 
left her, and the swelling diminished. 

About the 8th of June, she began to experience a return of 
the pains in the knee, and in the course of four or five days 
they w r ere so severe as to keep her awake at night. There 
were convulsive startings of the limb, and the joint was swollen 
in a greater degree than formerly. The pains increased in 
violence, and her health began to suffer considerably. On the 
3d of July the limb was amputated. 

On examining the knee, some lymph and serum were found 
effused into the cellular membrane external to it. 

The cavity of the joint contained about half an ounce of thin 
purulent fluid; the cartilage covering the patella was, in some 
parts, in a natural state; in others, it had the fibrous structure, 
which I have described in a former part of this chapter; and, 
in others, it was completely destroyed by ulceration, so as to 
expose the surface of the bone. The cartilage covering the 
articulating extremity of the femur presented the same variety 
of appearances. On the inside there was a spot of some extent, 
which, instead of cartilage, was covered by a kind of membrane, 
resembling the substance of adhesions, but somewhat more 
dense in its structure; as if the cartilage had been formerly de- 
stroyed at this part, and coagulated lymph had been effused on 
the ulcerated surface of bone, which had afterwards become 
organized. 

The cartilages of the tibia were ulcerated for a very small 
extent. 

The synovial membrane in general was in a natural state. 
In some places it was slightly inflamed. On the outside of the 
joint, it was inflamed in a greater degree than elsewhere, and 
thickened, and had begun to ulcerate, evidently in consequence 
of the abscess in the joint having begun to make its way to the 
external surface. 

The bones possessed their natural texture and hardness, 



OF THE ARTICULAR CARTILAGES. 79 

CASE XXXVII. 

Jane Bannister, forty years of age, was admitted into St. 
George's Hospital, in September, 1S10, on account of a disease 
in her ri^ht foot. She gave the following account of her 

case: — 

In the September of the preceding year she wrenched her 
instep, and soon afterwards experienced violent pain in this 
part, so that she was unable to stand on that foot, and her rest 
was much disturbed at night. The pain continued very severe, 
and, at the end of four months, she observed for the first time, 
a slight swelling on the inside of the foot. This was occasioned 
by an abscess, which was opened by her medical attendant in 
the April following. 

At the time of her admission into the hospital, the whole 
foot was swollen, and she complained of violent pain in it. 
The abscess continued open, discharging a small quantity of 
pus. On introducing a probe into the orifice, an exposed sur- 
face of bone was felt. Several applications were made without 
benefit, and the leg was amputated on the 25th of February. 
1811. 

On examining the amputated foot, the cartilages of the joint 
formed by the astragalus and os naviculare were found destroyed 
by ulceration, and a portion of the astragalus was dead, and un- 
dergoing the process of exfoliation. The cartilages of the joints 
formed bv the cuneiform bones with each other, with the os 
naviculare, and with the metatarsal bones, were in like manner 
destroyed, and the exposed surfaces of bone were carious. The 
abscess communicated with the carious joints. The ligaments 
and synovial membrane were in a natural state, except in a few 
spots, where they were destroyed by the abscess. The bones 
possessed their natural texture and hardness. The cellular 
membrane of the foot contained coagulated lymph and serum. 

CASE XXXVIII. 

Thomas Herbert, fifty-eight years of age, was admitted into 
St. George's Hospital, on the 14th of September, 1825. 

He complained of pain and tenderness of the left knee. 
The leg was kept in the half-bent posture; and there was a 
severe aggravation of the pain on every attempt to move it. 
There was a slight swelling of the joint, not arising from fluid 



80 ON THE ULCERATION 

collected in its cavity, but from an effusion into the cellular 
texture external to it. The man was in ill health, and his 
memory was impaired, so that no history of his case could be 
procured. 

Blisters were applied and kept open: but notwithstanding 
these remedies, joined with a state of complete repose, an ab- 
scess presented itself on the outside of the joint, and burst, dis- 
charging a large quantity of pus. It now became a question 
whether the limb should not be removed by amputation; but 
an attack of erysipelas prevented the operation. The patient 
gradually became more exhausted, and died in the beginning of 
December. 

On dissection, the cartilage of the patella of the left knee was 
found in some parts destroyed, so as to expose the surface of 
the bone; while in other parts it had lost its natural structure, 
and was converted into a fibrous substance. 

The cartilages of the head of the tibia and condyles of the 
femur, were almost every where destroyed, so that extensive 
surfaces of carious bone were exposed. 

The abscess did not communicate with the general cavity of 
the joint, but was limited to the portion of it formed by the ex- 
ternal condyle of the femur and the external articulating surface 
of the tibia; and here the cancellous structure of the bones ad- 
joining the ulcerated surfaces was of a dark colour. Every 
where else the bones belonging to the diseased joint retained 
their natural texture and hardness. 

In the right knee, which had been supposed, while the pa- 
tient lived, to be free from disease, the cartilage of the patella 
had, in some parts, entirely disappeared, so that the bone had 
become exposed: in other parts, it was converted into a fibrous 
substance; and in. other parts, it retained its natural structure 
and appearance. 

The cartilages of the femur and tibia of the right knee were 
somewhat thinner than natural, and of a yellowish-white colour; 
but they were entire, except on the edge of one of the condyles 
of the femur, where the cartilage was in a state of incipient ul- 
ceration, and the surface of the bone was of a red colour in a 
spot about one-third of an inch in diameter. The synovial 
membrane was in a natural state. 



OF THE ARTICULAR CARTILAGES. 81 

The following case affords an example of ulceration of the 
articular cartilages occurring as a secondary disease, the primary- 
disease having had the character of a rheumatic inflammation 
of the bone and periosteum. I have seen a few other cases ap- 
parently similar to this, but in which no opportunity occurred 
of ascertaining the exact nature of the disease by dissection. 
The history of one of these will be found among the cases re- 
lated hereafter. 

CASE XXXIX. 

Sarah Holder, twenty-two years of age, was admitted into 
St. George's Hospital, on the 26th of July, 1S27, with a diffused 
swelling extending from the upper part of the right thigh to the 
leg, a little below the knee. The swelling was most conspicu- 
ous in the immediate neighbourhood of the knee-joint; and 
from thence gradually became diminished, having no defined 
termination either above or below. It was somewhat elastic, 
the skin over it appearing glossy and tense, but not redder than 
natural. The patient complained of exquisite pain, especially 
on pressure. The pain was also aggravated by every motion 
of the knee; nevertheless it was principally referred, not to the 
joint itself, but to the thigh bone immediately above it. In ad- 
dition to these local symptoms, the pulse was frequent; the 
tongue furred, and rather brown; the skin hot; and the coun- 
tenance anxious and expressive of much suffering. The condi- 
tion of the patient was altogether a good deal similar to that 
which might be produced by severe rheumatic inflammation of 
the bone and periosteum; and the history of the case seemed to 
justify the opinion that such w 7 as the nature of the disease, as 
the symptoms had begun without any precursory rigor on the 
day previous to her admission, and had been preceded, for an 
entire month, by rheumatic pains in the elbows, and shoulders. 

Saline and antimonial medicines were exhibited: leeches 
were freely applied to the limb, and on the 28th of July, a pill, 
containing two grains of calomel and half a grain of opium, was 
exhibited twice daily. Under this treatment the gums became 
slightly affected, and the symptoms gradually abated. On the 
3d of August, the mercurial pill was given only once daily, and, 
in the course of a few days more, it was altogether discontinued, 
blisters being at the same time applied to the limb. 
8 



82 ON THE ULCERATION 

August 13. The swelling and pain had entirely left the up- 
per part of the thigh; but there were still some remains of both 
in the immediate neighbourhood of the knee. Altogether she 
was in a much better state with respect to the local symptoms, 
and the general health was improving. 

August 15. After an accidental exposure to cold, she had a 
rigor, followed by fever; and, at the same time, there was a 
recurrence of pain and swelling in the neighbourhood of the 
right knee, with some degree of pain and tenderness extending 
up the thigh, and down the leg. The swelling had the same 
character as formerly. 

August 20. She continued in nearly the same state, with 
painful startings of the limb, and perspirations at night. Pulse 
very frequent. She was directed to resume the use of calomel 
and opium. 

Sept. 2. There was no material improvement as to the local 
symptoms: a blister was applied to the knee. 

She continued in nearly the same state, sometimes a little 
better, sometimes a little worse, with a very frequent pulse, and 
the general health, on the whole, declining, until the 7th of Oc- 
tober; when an issue was made with caustic in the neighbour- 
hood of the knee. The issue seemed to occasion some abatement 
of the local symptoms. Her bodily powers, however, continued 
to decline, and she became affected with an ulcer over the sa- 
crum, the result of long-continued pressure. 

Oct. 14. She complained of severe pain in the left shoulder. 

Oct. 15. She was seized with vomiting and purging, accom- 
panied with pain and tenderness of the abdomen and cold ex- 
tremities. Pulse 140. At midnight she had a severe rigor. 

The vomiting and purging continued, in spite of the remedies 
which were employed. In the afternoon of October 16, she had 
another rigor, and in about two hours afterwards she expired. 

On examining the, body, the knee-joint was found to contain 
neither pus nor synovia. The cartilage of all the bones which 
enter into the composition of the joint were ulcerated in se- 
veral places, especially that of the inner condyle of the femur. 
A slight extravasation of blood had taken place into the cavity 
of the joint, apparently from the surfaces of the bone exposed 
in consequence of the ulceration of the cartilages. The perios- 
teum could be easily peeled off the surface of the femur, and the 



OF THE ARTICULAR CARTILAGES. S3 

bone underneath appeared to be more vascular than is natural. 
The stomach was distended with an acid fluid of a green colour, 
similar to what had been vomited on the day preceding death. 
The gall bladder was full of a very pale yellow fluid. There 
were no other morbid appearances. 

The left shoulder, to which pain had been referred for a short 
time previous to death, was carefully examined, but no disease 
was detected in it. 

It would be needless to add to the foregoing list an account 
of other cases, in which the disease w r as in a still more advanced 
stage. The progress of it, in other joints, corresponds with that 
in the hip; and whatever may be the joint affected, there is ul- 
timately the same complete destruction of the cartilages, and 
the same extensive ravages are committed among the bones and 
soft, parts. 



SECTION II. 

ON THE SYMPTOMS OF THIS DISEASE. 

The ulceration of the articular cartilages may occur at any 
period of life; but it is most frequent in those who have passed 
the age of puberty, and who are under thirty or thirty -five years 
of age. We meet with it, however, sometimes in young chil- 
dren, and at other times in old persons. In general, the disease 
is confined to a single joint; but occasionally two or three joints 
are affected in the same individual, either at the same time, or in 
succession. Sometimes the patient traces the beginning of his 
symptoms to a local injury; but for the most part no cause can 
be assigned for the complaint, and often, the cause to which it 
is attributed appears to be imaginary rather than real. 

It is this disease which forms the great majority of those 
cases of caries of the hip-joint which occur in adult persons; 
whereas, in children, the hip-joint is principally affected by that 
scrofulous disease affecting; the cancellous structure of the 
bones, which will be described hereafter. These two classes 
of cases have many circumstances in common; and as I shall. 



84 ON THE ULCERATION 

in the present chapter, enter into a minute history of the pro- 
gress of the former, I shall be enabled, in the next chapter, to 
confine my observations respecting the latter chiefly to those 
points of difference, on which our diagnosis, so far as it can be 
made, must mainly depend. 

Where the cartilages of the hip are ulcerated, as a consequence 
of inflammation of the synovial membrane, the peculiar symp- 
toms, which it presents, are preceded by those of the last-men- 
tioned disease; otherwise, the only symptoms met with for 
some time, are pain, and a slight degree of lameness in the 
lower limb. The pain at first is trifling, and only occasional; 
afterwards becoming severe and constant. It resembles a good 
deal the pain of rheumatism, since it often has no certain seat; 
but is referred to different parts of the limb in different indi- 
viduals, and even in the same individual at different periods. 
As the disease advances, the pain becomes exceedingly severe, 
particularly at night, when the patient is continually roused 
from his sleep by painful startings of the limb. Sometimes he 
experiences some degree of relief from the pain in a particular 
position of the joint, and in no other. A patient in St. George's 
Hospital never obtained any rest, except when he had placed 
himself on the edge of the bedstead, with his feet on the ground, 
and resting his body on a pillow, in a position between that of 
lying and sitting. Another patient was seen, night and day, 
crouching on his knees and elbows. 

As the pain increases in intensity, it is more confined in its 
situation. In the greater number of instances, it is referred to 
the hip and the knee also; and the pain in the knee is generally 
the most severe of the two. At other times, there is pain in 
the knee, and none in the hip. Sometimes there is pain referred 
to the inside of the thigh; or even to the foot. Wherever the 
pain is situated, it is aggravated by the motion of the joint; but 
it is aggravated in a still greater degree by whatever occasions 
pressure of the ulcerated cartilaginous surfaces against each 
other. Hence the patient is unable to support the weight of 
the body on the affected limb; and if he be placed on an even 
surface in a horizontal position, and the hand of the surgeon be 
applied to the heel, so as to press the head of the femur against 
the concavity of the acetabulum, violent pain is the consequence ; 
although this be done in so careful a manner that not the 



OF THE ARTICULAR CARTILAGES. 85. 

smallest degree of motion is given to the hip-joint. This cir- 
cumstance is well deserving of attention; and no one should at- 
tempt to give an opinion as to the nature of a disease connected 
with the hip, without having made an examination in the man- 
ner which has been just described. 

Soon after the commencement of the complaint, the hip-joint 
is found to be tender, whenever pressure is made on it, either 
before or behind. The absorbent glands in the groin become 
enlarged, and sometimes suppurate. Occasionally there is a 
slight degree of general tumefaction in the groin. In this there 
is nothing remarkable, since we must suppose that a disease 
going on within the articulation must ultimately occasion some 
degree of inflammation in the neighbouring parts. But it is a 
curious circumstance, that in some cases there is tenderness of 
those parts to which, though not diseased themselves, the pain 
is referred from sympathy with the disease in the hip. I have 
observed this in the knee several times; and I have also seen 
a slight degree of puffy swelling of this joint, where pain was 
referred to it, in consequence of disease in the hip. These facts 
correspond to what may be observed in some other cases, where 
pain is referred to a sound part, in consequence of a sympathy 
existing between it and some other part that labours under dis- 
ease;* for example, I have known the passage of a calculus down 
the ureter to occasion not only pain, but tenderness, swelling, 
and no trifling degree of inflammation of the testicle. 

When the disease has existed for some time, the nates under- 
go a remarkable alteration in their form. They become wasted 
and less prominent; so that, instead of their usual convexity, 
they present the appearance of a flattened surface; they are 
flaccid to the touch, and hang more loosely towards the lower 
edge; and they have the appearance of being wider than those 
of the other side. In a very few cases, in the advanced stage 
of the disease, the nates are really wider, in consequence of the 
acetabulum being filled with coagulated lymph and matter, and 
the head of the femur being pushed out of its natural situation. 
But, in general, the increased breadth of the nates is only ap- 
parent, and, on an accurate measurement, no difference in this 
respect will be found between the nates of one side and those 
of the other. The alteration in the figure of the parts, in these 
cases, may arise partly from the position in which the patient 

8* 






86 ON THE ULCERATION 

usually places himself when he stands ereet; but the principal 
cause to which it is to be attributed, is the wasting of the large 
fleshy bellies of the glutaei muscles from want of use; and this 
has been ascertained, by repeated and accurate examinations of 
the living, and numerous dissections of the dead, body.* 

Another symptom which occurs in this disease, is an altera- 
tion in the length of the limb. 1st, In the early stage of the 
disease the patient often complains, that the limb on the affected 
side is longer than the other. This cannot be explained on 
the supposition of the acetabulum being filled with pus, or solid 
substance, since this would cause the head of the femur to be 
pushed outwards rather than downwards. The fact is, that 
there is only an apparent, and no real, elongation of the limb. 
If the patient be placed on his back in the horizontal position, 
with the thighs parallel to each other, the foot on the diseased 
side may at first appear as much as two or three inches lower 
than the opposite foot; but, if the distance be accurately mea- 
sured from the anterior superior spinous process of the ilium of 
the patella, no difference is perceptible. The apparent elonga- 
tion is produced by the position of the pelvis being altered, in 
such a way that the crista of one ilium is visibly depressed be- 
low the level of that of the other. It is easy to understand how 
this effect is produced, by observing the position in which the 
patient places himself when he stands erect. He supports the 
weight of his body on the sound limb; the hip and knee of which 
are, in consequence, maintained in the state of extension. At the 
same time the opposite limb is inclined forward, and the foot 
on the side of the disease is placed on the ground, considerably 
anteriorly to the other; not for the purpose of supporting the 
superincumbent weight, but for that of keeping the person 
steady, and preserving the equilibrium. Of course, this cannot 
be done without the pelvis on the same side being depressed. 

* This alteration in the form of the nates is a symptom, but is not in itself 
to be considered as a certain diagnostic mark of disease in the hip-joint; as it 
may be observed in other cases, where, from any cause, the glutaei muscles 
have been for a considerable time in a state of inaction. Thus children are 
subject to a paralytic state of the muscles of the lower limb; and in this com- 
plaint, if the muscles are affected as high as the pelvis, the nates present to 
the eye the same appearance. It may be noticed also where there is disease 
of the thigh-bone, or where, from any other cause, the motion of the hip is pain- 
ful and difficult. 



OF THE ARTICULAR CARTILAGES. 87 

The inclination of the pelvis is necessarily attended with a la- 
teral curvature of the spine; and hence it happens that one 
shoulder is higher than the other, and that the whole figure is 
in some degree distorted. All these symptoms will disappear 
in the course of a few weeks, if the patient be confined to his 
bed in the supine and horizontal position; except in some in- 
stances, where, in consequence of their having occurred in a 
young and growing person, and having already been allowed 
to exist for a considerable time, the shape of the parts has be- 
come adapted to their new situation. Under these circum- 
stances, the alteration of the figure may continue during life. 

2. In a few cases, where the patient is in the erect position, 
it may be observed that the foot which belongs to the affected 
limb is not inclined more forward than the other, but that the 
toes only are in contact with the ground, and the heel raised; 
at the same time that the hip and knee are a little bent. This 
answers to the patient the same purpose of enabling him to 
throw the weight of his body on the other foot; but it pro- 
duces an inclination of the pelvis in the opposite direction. The 
crista of the ilium is higher than natural, and there is an ap- 
parent shortening, instead of elongation, of the limb on the side 
of the disease. 

3. In the very advanced stage of the disease, when the head 
of the femur has been completely destroyed by ulceration, there 
is nothing to prevent the muscles from pulling the bone up- 
wards. This may be compared to a case of fractured neck of 
the femur. The limb is not only apparently, but it is really, 
shortened ; the foot may be rotated inwards, but, if left to itself, 
it generally is turned outwards. 

4. In other cases, the limb is shortened; the thigh is bent 
forwards; the toes are turned inwards, and do not admit of 
being turned outwards; and there is every symptom of a dis- 
location of the hip upwards and outwards. The following case 
fully explains the cause of these appearances. 

CASE XL. 

Taylor, a middle-aged man, was admitted into St. 



George's Hospital in the autumn of 1S05, on account of a dis- 
ease in his left hip. He laboured also under other complaints; 
and he died in the February following. 



88 ON THE ULCERATION 

On inspecting the body, the soft parts in the neighbourhood 
of the joint were found slightly inflamed, and coagulated lymph 
had been effused into the cellular membrane round the capsular 
ligament. 

There were no remains of the round ligament. 

The cartilages had been destroyed by ulceration, except in a 
few spots. 

The bones, on their exposed surfaces, were carious; but they 
retained their natural form and size. The acetabulum was al- 
most completely filled with pus and coagulated lymph; the 
latter adhering to the carious bone, and having become highly 
vascular. The head of the femur was lodged on the dorsum of 
the ilium. The capsular ligament and synovial membrane 
were much dilated; and, at the superior part, their attachment 
to the bone was thrust upwards, so that, although the head of 
the femur was no longer in the acetabulum, it was still within 
the cavity of the joint. 

Since the man did not attribute this disease to any local 
injury, we may conclude that the ulceration of the cartilage 
was the primary affection, and that the dislocation had been 
produced in consequence of the destruction of the round liga- 
ment, and of the head of the femur having been first pushed 
outwards by the coagulated lymph and pus which occupied the 
cavity of the joint, and then drawn upwards by the action of 
the muscles inserted into the great trochanter.* 

The shortening of the limb, which takes place in the ad- 
vanced stage of the disease, is usually, but not always, the pre- 
cursor of abscess. The formation of matter is also indicated 
by an aggravation of pain, by more frequent spasms of the 
muscles, by a greater wasting of the whole limb, and by the cir- 
cumstance of the thigh becoming bent forward, and being inca- 
pable of extension without such an increase of the patient's 
sufferings as he will be unable to endure. At the. same time 
the pulse becomes frequent, the tongue furred, and the whole 
system is in a state of preternatural excitement. The abscess 
sometimes shows itself in the form of a large tumour over the 

* This case affords one example of the dislocation of the hip from an in- 
ternal cause, which some surgical writers have described. Other examples 
of this kind of dislocation occur in cases of inflammation of the synovial mem- 
brane, as has been explained in a former chapter. 



OP THE ARTICULAR CARTILAGES. 89 

vastus externus muscle; sometimes on the inside of the thigh, 
near the middle; and occasionally two or three abscesses ap- 
pear in different parts, and burst in succession. The abscesses 
discharge a large quantity of thin pus; and, in the worst cases, 
a copious suppuration continues, until the powers of the patient 
are exhausted; so that, enfeebled and emaciated, he sinks under 
the symptoms of a hectic fever. That an adult should reco- 
ver under these circumstances, is so rare an occurrence, that the 
surgeon can never be justified in giving any but the most un- 
favourable prognosis. Children recover more frequently in 
this advanced stage of the disease; but seldom without a com- 
plete anchylosis of the joint. If suppuration has not taken 
place, it generally, but not always, happens, that the limb, after 
the cure, regains its natural degree of mobility.* 

When the cartilages of the knee are ulcerated, there is pain 
in the affected joint. At first, it is slight and only occasional, 
and, in the early stage of the disease, it is completely relieved 
by the limb remaining in a state of rest for a few days; but it 
returns as soon as the patient resumes the exercise of the limb. 
By degrees the pain becomes constant and very severe, parti- 
cularly at night, when it disturbs the patient by continually 
rousing him from his sleep. The pain is referred principally 
to the inside of the head of the tibia; but sometimes a slighter 
degree of pain extends down the whole of that bone. The 
pain is aggravated by motion, so that the patient keeps the 
limb constantly in one position, and generally half bent: and 
he never attempts to support the weight of the body on the 
foot of this side. 

The ulceration of the cartilages of the knee differs, with re- 
spect to its symptoms, from inflammation of the synovial mem- 

* The morbid affections of the hip most liable to be confounded with that 
which has been above described, are the following: — 

1. Inflammation of the synovial membrane. 

2. Scrofulous disease, having its origin in the bones, of which I shall speak 
hereafter. 

3. A painful nervous affection, which occurs chiefly in young females dis- 
posed to hysteria; which will also be noticed in a subsequent chapter. 

4. Affections of the sciatic nerve, of the upper part of the femur, and 
other diseases external to the hip, are not unfrequently mistaken for disease 
in the joint itself, especially by surgeons of limited experience, who are mis- 
led by the wasting of the glutei muscles, and the flattened appearance of the 
nates, which may occur in any one of these cases. 



90 ON THE ULCERATION 

brane, in this, — that the pain in the former is slight in the be- 
ginning, and gradually becomes very intense, which is the 
very reverse of what happens in the latter. But there is an- 
other circumstance, which forms a remarkable distinction be- 
tween the ulceration of the cartilages, and most other diseases 
to which this joint is liable. The pain, in the first instance, is 
unattended by any evident swelling; which comes on never in 
less than four or five weeks, and often not until several months 
have elapsed, from the commencement of the disease. The 
reason of this is too manifest to require explanation, and it is 
equally unnecessary to point out the importance of it, as afford- 
ing the means of making a more ready diagnosis. We must 
not, indeed, conclude indiscriminately, whenever there is a 
slight pain in the knee, unattended by swelling, that the car- 
tilages are in a state of ulceration, since this symptom may 
equally arise from inflammation of the bones themselves; of 
the ligaments; of the fatty substance of the joint; or from sim- 
ple nervous affection: and instances will occur to every surgeon, 
where there is reason to believe that the above-mentioned 
symptom arises from one or other of these causes. But when 
the pain continues to increase, and at last becomes very severe; 
when it is aggravated by the motion of the joint, and by the 
pressure of the articulating surfaces against each other; and 
when, after a time, a slight tumefaction takes place, such as I 
shall presently describe; we may conclude that the disease con- 
sists in an ulceration of the cartilages; and, in all such cases 
which have come under my own observation, their subsequent 
progress, and the morbid appearances presented by dissection, 
where an opportunity has occurred of observing them, have 
fully justified this conclusion. 

The swelling which attends this disease, in the knee, differs 
from that which occurs in either of those diseases of the syno- 
vial membrane which I have formerly described. It arises 
from a slight degree of inflammation having taken place in the 
cellular membrane external to the joint, in consequence of the 
disease within it.- The swelling is usually trifling, appearing 
greater than it really is, in consequence of the wasting of the 
muscles of the limb. It has the form of the articulating ends 
of the bones; that is, the natural form of the joint. No fluctua- 
tion is perceptible, as where the synovial membrane is inflamed; 



OF THE ARTICULAR CARTILAGES. 91 

nor is there the peculiar elasticity which exists where the syno- 
vial membrane has undergone a morbid alteration of structure. 

But a few cases occur in which this disease is attended with 
a collection of fluid in the joint, and in which, therefore, the 
tumour has a form different from that which has been described, 
and giving to the hand a distinct sense of fluctuation. 

1st. Inflammation of the synovial membrane may terminate 
in ulceration of the cartilages; in which case it sometimes hap- 
pens, that the fluid, secreted into the cavity of the joint, in 
consequence of the primary disease, is absorbed ; while, in other 
cases, it is not absorbed before the peculiar symptoms of the 
secondary disease have shown themselves; or, 

2dly. This order may be reversed; inflammation of the syno- 
vial membrane being the secondary disease, ulceration of the 
cartilages having preceded it, and the effusion of synovia into 
the joint being the consequence of it. This I supposed to have 
happened in the case of John Child; which will be related here- 
after. 

3dly. In an advanced stage of ulceration of the cartilages, 
where an abscess is formed, it occasions ulceration of the soft 
parts, and usually makes its way to the skin; but sometimes 
the pus is collected in the joint, distending the synovial mem- 
brane, and causing a tumour very similar to that which would 
arise from it being distended with synovia. In these cases, 
the surgeon must form his diagnosis, by attending to the pre- 
vious history; by observing the degree and the kind of pain of 
which the patient complains; and the state of his general health; 
and by bearing in mind this circumstance, that blisters, com- 
bined with rest, very seldom fail in procuring absorplion c-f the 
too abundant synovia, and that they never cause the absorption 
of pus. 

As the ulceration of the cartilages is sometimes followed by 
dislocation of the hip; so we find that dislocation of the knee 
occasionally takes place from the same cause. Where there 
has been considerable destruction of the soft parts, in conse- 
quence of ulceration extending to them, the head of the tibia 
is gradually drawn backwards by the action of the flexor mus- 
cles, and lodged in the ham; and I have even known this to 
happen where abscess has never formed, the patient ultimately 
recovering with a stiff joint and disfigured limb. In such a 



92 ON THE ULCERATION 

case, the condyles of the femur make an unusual projection, 
and the articulating surfaces of the bones are partially, or en- 
tirely, separated from each other. 

The symptoms produced by the ulceration of the cartilages 
of other joints correspond very nearly with those already de- 
scribed. The principal diagnostic mark is the pain, which is 
experienced in the beginning unattended by swelling, and which 
is invariably increased by the pressure of the articulating sur- 
faces against each other. The pain is referred to the part which 
is the actual seal of the disease : but, where the elbow is affected, 
the more violent pain in this joint is accompanied by a slighter 
degree of pain in the lower part of the fore-arm and wrist; and 
where the disease is in the shoulder, there is often a painful 
sensation, extending down the whole of the bone of the arm. 
In cases of ulceration of the cartilages of the shoulder, the joint 
is smaller than natural, in consequence of the wasting of the 
deltoid muscle. When an abscess forms in connexion with 
this joint, it often assumes a somewhat singular appearance, 
when it has first penetrated through the deltoid muscle; so that 
I have known it more than once to be mistaken for an en- 
cysted tumour. In the advanced stage of the disease in the 
shoulder, the joint is liable to be dislocated in the direction 
forwards. Sometimes the dislocation is only occasional, the 
head of the bone slipping forwards, so as to make a visible pro- 
jection, in certain motions of the arm, and again returning to 
its place; at other times, the dislocation is permanent, the head 
of the bone resting on the anterior margin of the glenoid cavity 
of the scapula, and gradually making a new cavity for itself in 
this situation. 

Whatever joint is the seat of the disease, the formation of 
abscess is always attended wnth an aggravation of all the symp- 
toms. But the degree in which the general system is disturbed, 
when suppuration is established, depends on various circum- 
stances; such as the age and powers of the patient; the size of 
the affected joint; and its situation. An abscess connected w T ith 
a deep-seated joint occasions more extensive mischief of the 
soft parts, before it reaches the surface, and, therefore, is pro- 
ductive of more serious consequences, than one which is con- 
nected with a joint which is situated superficially. 

The progress of the ulceration of the cartilages varies, with 



OF THE ARTICULAR CARTILAGES. 93 

respect to time, in different cases, but it is generally tedious. 
In one case, in which violent pain had existed in the knee, with 
little or no swelling, for two years and a half previous to am- 
putation, 1 had an opportunity of examining the diseased joint, 
and found the cartilages destroyed for only a small extent; a 
drachm and a half of pus in the articular cavity; and no morbid 
appearances of the soft parts, with the exception of a very slight 
inflammation, which had been induced in the synovial mem- 
brane, and the effusion of a minute quantity of coagulated lymph 
into the cellular texture on its external surface. In another, 
case, the pains in the lower limb had existed for a whole year, 
before they were sufficient to attract the patient's serious at- 
tention. No pus w T as formed in the joint; and the ultimate re- 
covery was complete, without the smallest detriment to the 
motion of the limb. But at other times, the progress of the 
disease is much more rapid. There was a patient in St. George's 
Hospital, in whom, in the course of four months, the destruc- 
tion of the head of the femur and acetabulum was such, as to 
occasion a real shortening of the limb to the extent of an inch. 



SECTION III. 

ON THE TREATMENT. 

It is, of course, of importance that attention should be paid 
to the general health, and that such internal remedies should 
be exhibited as are indicated by the peculiar circumstance of 
each individual case. If there be a febrile excitement of the 
system, saline and antimonial medicines, and occasional purga- 
tives are proper. Where the patient, in the advanced stage of 
the disease, finds his bodily powers enfeebled, and is troubled 
with nocturnal perspirations, bark, or some other vegetable 
tonic, combined with mineral acids, may be given with advan- 
tage; and opium, or extract of poppies, may be administered to 
those whose rest is disturbed by attacks of excruciating pain. 
Where the disease in the joint is attended with a disordered 
condition of the functions of the digestive organs, it is undoubt- 
edly proper to endeavour by suitable remedies to restore these 
to a more healthy state. 
9 



.94 ON THE ULCERATION 

I cannot doubt that a course of sarsaparilla, properly pre- 
pared, and administered in full doses, is often productive of the 
greatest benefit; and still greater and more immediate relief is 
•ometimes obtained from the exhibition of mercury. For this 
purpose I have usually had recourse to calomel, combined with 
extract of hyoscyamus or opium, one or two grains being given 
twice or three times daily, so as to affect the gums moderately. 
It seems probable that such specific remedies are especially 
adapted to those cases in which the ulceration of the cartilage 
is connected with a chronic inflammation of the surface of the 
bone beneath. Analogy will lead us to expect that the hydri- 
odate of potash may be useful under the same circumstances. 
Those thickenings of the periosteum, called nodes, are for the 
most part preceded by a chronic inflammation of the bone 
which the diseased periosteum covers, and these disappear 
equally under the use of the hydriodat'e of potash, mercury, 
and sarsaparilla. 

When the cartilages of a joint are ulcerated, it may well be 
supposed that the motion of their surfaces on each other must be 
favourable to the progress of ulceration. I have known some 
cases, in which rest alone was sufficient to produce a cure. In 
all cases, the symptoms of the disease are aggravated by any 
considerable exercise; and we may, therefore, conclude that the 
keeping the limb in a state of the most perfect quietude, is a 
very important, if not the most important, circumstance to be 
attended to in the treatment. When the affected joint is in the 
lower limb, the patient should be confined to the bed, or, at 
any rate, to the sofa. In most instances, some contrivance may 
be employed having for its object to maintain the diseased 
joint in a state of absolute immobility; and this should be al- 
ways regarded as one of the principal points to be attended to 
in the surgical treatment. The apparatus made use of for this 
purpose should be such as is efficient, and, at the same time, 
simple, light, and commodious to the patient. The plasters 
and bandages recommended by Mr. Scott, in the work to which 
I have formerly referred, operate, as I conceive, on the princi- 
ple which has been here laid down, and are often productive of 
benefit. But according to my experience, splints of leather, 
applied after being softened by heat and moisture, and then al- 
lowed to dry on the limb, are much preferable to all other ex- 



OF THE ARTICULAR CARTILAGES. 95 

pedients. The)^ must exactly fit the joint, and therefore are 
easy to be worn: they may be retained in their proper place 
with any little pressure on the parts which they enclose; and 
they admit of being taken off and re-applied with the greatest 
ease. 

Issues made with caustic* have been recommended by many 
practitioners for the cure of diseased joints; but, as far as I 
know, no one has attempted to point out the particular class of 
cases, to which this remedy is particularly applicable. I have 
employed caustic issues, and seen them employed, in a great 
number and variety of instances, and have found them to be 
usually productive of singular benefit where the cartilages are 
in a state of ulceration, and to be of much more service in these 
than in the other morbid affections to which the joints are liable. 
Setons and blisters, kept open by means of the savine cerate, 
appear to operate nearly in the same manner as caustic issues, 
and may be used with advantage in the same description of 
cases.f 

* The immediate relief which sometimes follows the application of caustic 
to the skin, or the surface of an issue, when the limb is under precisely the , 
same circumstances as before with respect to rest, and the return of the symp- 
toms which, in many instances, follows the early healing of an issue, suffi- 
ciently proves the efficacy of this remedy. It may be difficult to explain the 
modus operandi; but what happens in these cases seems to bear no distant 
analogy to the suspension of gonorrhoea by the occurrence of inflammation of 
the testicle, or the metastasis of gout from the stomach to the foot. Issues 
are employed in surgery for the purpose of stopping the morbid actions of the 
animal body; but it is probable that, if made of too great an extent, they would 
interfere with its natural actions also. In a guinea-pig, a large abscess took 
place of one leg and thigh, in consequence of a local injury. The formation 
of the abscess completely stopped the growth of the claws on the foot of this 
side. They wore away at the points, without being regenerated at the base: 
became short and dry, and readily cracked and splintered; while, on the foot 
of the opposite limb, they continued to grow as usual, and possessed their or- 
dinary appearance. 

t It maybe expected that I should, in this place, offer some remarks on the 
effects of the application of the actual cautery in the form of the hot iron, or 
the moxa, which has been recommended, at different times, for the relief of 
some cases of diseased joints. I do not, however, feel myself warranted in 
giving any confident opinion as to the comparative efficacy of issues made by 
the caustic, and those made by the cautery; my experience of the latter being 
much more limited than that of the former. What I have seen, however, 
does not lead me to believe that the cautery is in any respect more efficient 
than the caustic; and there are, certainly, some considerable objections to its 
use. to which the caustic is not liable. 



96 ON THE ULCERATION 

Local blood-letting, or even bleeding from the arm, is occa- 
sionally productive of advantage in the beginning; especially in 
cases, which occur chiefly in the hospital practice, in which the 
patient, from too freely exercising the limb, has brought on an 
inflammation of the ulcerated surfaces, occasioning an aggrava- 
tion of the pain, and usually some degree of fever. 

In the early stage, the warm bath is sometimes of service, 
At least, it is capable of relieving the symptoms, if not of stop- 
ping the progress of the disease. 

Plasters made of gum ammoniac, and others. of a similar na- 
ture; embrocations and liniments of all kinds, are entirely in- 
efficacious. Friction is invariably injurious. 

1 have shown, in a former section, that ulceration of the ar- 
ticular cartilages may take place to a considerable extent, with- 
out suppuration being established. This is a circumstance of 
much interest in pathology, and in a practical point of view of 
great importance. The prospect of a cure which the employ- 
ment of any remedies affords is undoubtedly much greater 
where abscess does not exist, than where it does; and the prog- 
nosis, which the surgeon gives, must depend in a great degree 
on the opinion which he is led to form on this subject. 

Having premised these general observations, I shall proceed 
to offer some practical remarks: first, on the treatment of this 
disease in the hip, and afterwards in other joints, without re- 
ference to suppuration having taken place; secondly, on the 
plan, which should be adopted where suppuration is established, 
and there is a collection of pus communicating with the articu- 
lar cavity. 

When the cartilages of the hip are ulcerated, the patient 
should be confined to his bed or couch, being never allowed to 
move from it on any occasion. If left to himself, he is gene- 
rally inclined to lie on the side opposite to that of the disease. 
There are, however, good reasons why this position should be 
avoided, if possible. It necessarily distorts the pelvis, and in- 
creases the disposition to a lateral curvature of the spine. It 
also, in those cases in which the round ligament of the joints 
is destroyed, facilitates the escape of the head of the femur from 
the acetabulum, and the production of dislocation. Some- 
thing may be done towards preventing this last effect, by in- 
terposing a pillow, or thick cushion, between the knees; and it 



OF THE ARTICULAR CARTILAGES. '7 

is difficult to Jo more than this, after the patient has already 
been lying on his side for a considerable time: otherwise he 
should be placed on one of the bedsteads invented by Mr. Earle. 
lying on his back, with the shoulders and thighs somewhat ele- 
vated, and the latter as nearly as possible parallel to each other. 
This supersedes the necessity of having recourse to splints and 
bandages, and, with a view to the confinement of the hip-joint, 
is all that is required in the early stage of the disease.* At a 
later period when, in consequence of the extensive destruction 
of the articulation, the muscles begin to cause a shortening or 
retraction of the limb, I have found great advantage to arise 
from the constant application of a moderate extending force, 
operating in such a manner as to counteract the action of the 
muscles. For this purpose an upright piece of wood may be 
fixed to the foot of the bedstead, opposite the diseased limb, 
having a pulley at the upper part. A bandage may be placed 
round the thigh above the condyle, with a cord attached to it. 
passing over the pulley, and supporting a small weight at its 
other extremity. I will not say that the effect of such a con- 
trivance is to prevent the shortening of the limb altogether; but 
I am satisfied that it will, in a number of instances, render it 
less than it would have been otherwise, at the same time pre- 
venting, or very much diminishing that excessive aggravation 
of the patient's sufferings with which the shortening of the 11 . 
sually accompanied. 

The use of the bedstead which I have mentioned is quite- 
compatible with the employment of any method of counter- 
ritation which may seem to be best adapted to the peculiar cii- 
cumstances of the individual case. 

In children, blisters are capable of affording complete relief. 
They may be applied, of a small size, on the nates, round the 
greater trochanter, and in the groin. A blister, kept open by 
means of the savine cerate, is usually more efficacious in t 
disease than a number of blisters applied and healed in succes- 
sion. 

In adults, the same treatment is useful in the very early stage 
the disease; but, in the more advanced stage, issues made 

* On some occasions, however, it is convenient to fix the pelvis by a si 
OT bandage, passing over it, from one side of the bedstead to the other: and 
even the thigh may be fixed in the same manner. 

9* 



98 ON THE ULCERATION 

with caustic appear to be much more efficacious, and to be at- 
tended, on the whole, with less inconvenience to the patient. 

The hollow behind the great trochanter of the femur, is, in 
many respects, the most convenient situation for the applica- 
tion of the caustic; but, in some cases, the application of it on 
the outside of the hip is attended with better effects. The skin 
of this part is, in fact, nearer to the joint than the skin behind; 
and there are some grounds for the opinion, that issues are more 
efficacious when made near to the seat of disease than when 
made at a distance from it.* The skin in the groin is still 
nearer to the hip than that on the outside, but the larger vessels 
and nerves of the thigh forbid the use of the caustic at this part. 
A slough may be made with the caustic potash in the adult, 
half an inch in breadth, and two inches in length, behind the 
great trochanter. If this fails in giving relief, a second slough 
of a smaller size may be made on the anterior edge of the ten- 
sor vaginse femoris muscle; and, in some instances, though no 
relief is afforded by the first issue, there is great relief from the 
second. 

The good derived from the issue does not seem to be in pro- 
portion to the quantity of pus discharged from its surface. It 
has been observed by others, that sometimes more abatement 
of the symptoms is produced in the first few days after the 
caustic is applied, anpl before the slough has separated, than in 
several weeks afterwards. This circumstance first led me, in- 
stead of employing beans for this purpose, to keep the issue 
open simply by rubbing the surface occasionally with the caustic 
potash, or with the sulphate of copper; and, after an extensive 
trial of both methods, the latter has appeared to be decidedly 
preferable to the former. The pain produced by the caustic is 
very considerable, but the relief of the symptoms is such, that 
I have known patients to be in the habit of making the appli- 

* " I have for many years applied caustics above and below the internal con- 
dyle of the thigh-bone, for white swellings of the knee, with various success; 
and I have remarked that, where this plan disappointed my hopes, and where 
a suppuration took place in the joint, the inflammation in almost every case 
arose, and the matter collected made its way outwards, on the external side of 
the knee. Observing this fact repeatedly, I was led to believe that the caus- 
tic, in the manner I used it, checked the progress of the disease as far as it 
had influence; but that the influence was not sufficient to pervade the whole 
cavity of the joint." — Ford on the Hip-joint, p. 194, first edition. 



OP THE ARTICULAR CARTILAGES. 99 

cation themselves, saying, that "they knew they should be 
better by the next morning/' Besides, the issue managed in 
this way is more easily dressed than where beans are used; and 
the inconvenience arising from the beans slipping out under 
the adhesive plaster, and from any accidental pressure of them 
against the sore surface, is avoided. 

The cases in which complete relief of the symptoms imme- 
diately follows the making the issue, are not very numerous. 
In general, there is some degree of abatement on the caustic 
being applied; and, in a few weeks afterwards (provided that 
suppuration has not taken place,) if the patient continues in a 
state of quietude, the pain entirely leaves him. Where the pain 
is exceedingly severe (as it sometimes is, so as to prevent sleep 
during many successive nights,) it is very desirable that some 
method should be adopted, capable of affording more speedy re- 
lief than that which can usually be obtained from the applica- 
tion of the caustic. As I have already stated, if there be rea- 
son to believe that the ulcerated surfaces are in a state of in- 
flammation, in consequence of the joint having been too much 
exercised, bleeding may be had recourse to. A blister may be 
applied to the groin, and repeated if necessary. Blisters applied 
to the knee, or to the thigh, though there is no actual disease 
in these parts, will often occasion considerable, or even entire, re- 
lief of the pain, which is referred to these parts in consequence 
of their sympathy with the hip. This is a curious circumstance; 
but I have known it happen in so many instances, that, how- 
ever difficult it may be to explain it, I can entertain no doubt 
of the fact. Sometimes the pain is altogether relieved by the 
application of the blister; at other times I have known it leave 
the knee to which the blister was applied, and attack the hip. 

The objections which may be urged against the application 
of caustic to the skin of the groin do not hold good with re- 
spect to a seton in this situation. I was led to adopt this treat- 
ment some years ago, partly from observing that the skin of 
the groin is nearer to the hip-joint than the skin elsewhere; 
partly from an expectation (though not a very confident one,) 
that the making a seton over the trunk of the anterior crural 
nerve might be particularly calculated to relieve the pain re- 
ferred to those parts, to which the branches of that nerve are 
distributed. The results of this practice more than realized 



100 ON THE ULCERATION 

whatever hopes I had entertained of its success. In many 
cases the seton occasioned very speedily a complete relief of 
the pain. In other cases, indeed, it failed in producing the 
like good effects; but these cases have borne only a small pro- 
portion to those in which it has succeeded. On the whole, I 
am led to conclude, that where the pain is very severe, the se- 
ton in the groin is more calculated to afford immediate relief 
than the caustic issue; but that it is not so efficacious in check- 
ing the progress of the disease, as it is in lessening the violence 
of its symptoms ; and that the caustic issue can be better depend- 
ed on for the production of a cure.* 

* " The following are extracted from notes, which were taken formerly, 
when I was making observations on this subject. I will not undertake to say, 
that in every one of these cases, the disease was precisely that which is now 
under our consideration. Probably, in some of them, it was that scrofulous 
affection which will be described hereafter; but they equally serve to il- 
lustrate the effects of the seton in the groin, when the patient is exhausted 
by pain in consequence of disease in the hip. 

" November, 1808. 

" Martha Atkinson, fifteen years of age, laboured under symptoms of ul- 
ceration of the cartilages of the hip. She had pain in the hip and knee, but 
that in the hip was the more severe of the two. Her sufferings were such, 
that she could not venture to make the slightest alteration in her position; 
and she could scarcely procure any rest at night. 

" November 20, a seton was made in the groin. 

" November 22, the pain in the hip was almost completely relieved; and 
from this time she mended rapidly. 

u John Selly, eleven years of age, was admitted into St. George's Hospi- 
tal on the 28th of December, 1808, with severe pain in the hip and knee: 
tenderness in the region of the hip, and enlargement of the glands in the 
groin. 

" December 30, a seton was made in the groin. 

"The pains in the hip and knee were almost completely relieved wilthin a few 
hours after the seton was introduced. The relief was permanent, and on the 
24th of May following he left the hospital as cured. 

" Susan Dean, about twelve years of age, was admitted into St. George's 
Hospital, in November, 1808, with very severe pains in the hip and knee, in 
consequence of disease jn the former joint. A large abscess presented itself 
on the upper and outer part of the thigh. 

" On the 4th of December, a seton was made in the groin. The pains 
were relieved on the same afternoon. She had no return of pain while she 
continued in the hospital, but, as her friends took her away in a few weeks 
after the seton was made, 1 had no opportunity of observing the termination 
of the case. 

" James Craven, a young man, was admitted an out-patient of St. George's 
Hospital, on the 15th of March, 1809, with the usual symptoms of ulceration 
of the cartilages of the hip. There was a large abscess on the outside of the 
thigh, and intense pain in the knee, preventing his rest at night. 



OF THE ARTICULAR CARTILAGES. 101 

To make the seton in the groin, it is convenient to use a 
curved seton-needle. In the majority of cases, the patient 
keeps the thigh considerably bent on the pelvis; and this po- 
sition of the limb makes it difficult to employ a needle of the 
usual form. The seton may be introduced obliquely on the 
anterior part of the joint, including from one inch and a half 
to two inches of the integuments. After some time the skin 
over it usually inflames and ulcerates, and the seton drops out; 
but this does not happen before it has produced all the benefit 
which may be expected from it. 

Of the above observations on the ulceration of the cartilages 
of the hip, many are applicable to the disease in other joints. 

In all cases it is indispensable that the parts affected should 
be kept in a state of the most complete repose, and this is to 
be accomplished by various means, accordingly as one or ano- 
ther joint is the seat of the disease. In some instances, when 
the disease is in the knee, or ankle, or tarsal joints, nothing can 
be done better in the first instance than simply to lay the joint 
on an air pillow, which, if not much distended with air, gives a 
uniform, regular, and most convenient support on every side; 
but, for the most part, it is better to have recourse to splints 
made of pasteboard, or stiff leather, neatly moulded to the figure 
of the limb. When the disease is in the shoulder, the fore 
arm should be supported by a light leathern boat, suspended 
from the waist or neck, and the arm should be kept constantly 
bound to the side, and when it is in the ankle, great advantage 
will often arise from the patient wearing a common wooden 
leg, which will enable him to take exercise for the mainte- 
nance of his general health, without aggravating the local dis- 
ease. 

But whatever may be the mechanical means adopted for the 
purpose of preventing the motion of the diseased parts, care 
must be taken that they do not interfere with the use of those 

" March 16, a seton was made in the groin. Being unable to become an 
in-patient of the hospital, he walked home afterwards. Nevertheless, the 
pain was completely relieved in a few hours, and he slept soundly at night, 
the pain not at all disturbing him. 

11 After this, the abscess burst, and collected again several times; and he 
became affected with hectic symptoms. I did not see the termination of the 
case, but I make no doubt of it having ended fatally." 



102 ON THE ULCERATION 

external, or counter-irritants, the great efficacy of which may 
be said to have been established by the experience and con- 
sent of surgeons of all ages and countries. 

Where the knee or elbow is affected, we may employ the 
caustic issue, or the blister kept open by means of the savine 
cerate, but the former appears to be the most efficacious of the 
two. In the knee, a narrow slough may be made by rubbing 
the skin with the caustic potash on each side of the patella; 
and, in the elbow, the caustic may be applied in the same 
manner on the inside, and on the outside of the joint. When 
1 have met with this disease in the shoulder, I have sometimes 
employed a large blister, and kept it open by means of the sa- 
vine cerate; and in other cases I have made two caustic issues, 
one on the anterior, the other on the posterior part of the 
joint; and, on the whole, the caustic issues have appeared to be 
productive of better effects than the blister. Where the dis- 
ease has its seat in those joints which are surrounded by nu- 
merous tendons, as the wrist and ankle, it may be more pru- 
dent to employ the blister, lest injury should be done to the 
Superficial tendons by the application of the caustic. I have, 
however, in several cases made a caustic issue below the inter- 
nal or external malleolus. It has produced the best effects with 
respect to the disease in the ankle, but has been sometimes 
attended, otherwise, with unusual irritation and distress to the 
patient, so that it was with difficulty that he could be induced 
to allow it to be kept open for a sufficient length of time. 

. I have seen many cases in which the caustic issue has in 
the first instance removed all the symptoms of the disease; and 
yet, after some time, notwithstanding that the patient has re- 
mained in a state of perfect quietude, and there has been no 
evident cause of aggravation, they have returned nearly in 
the same form as before, and with their original severity. 
In some of these cases, their recurrence is to be attributed to 
the issue itself; which, from some cause, that the present 
state of our knowledge does not enable us to explain, pro- 
duces an effect, apparently the opposite to that which it produced 
when it was first made. The issue being allowed to heal, the 
symptoms again subside, and perhaps the patient may find 
himself entirely and permanently relieved before the sore is 
completely cicatrised. The same thing may be observed, per- 



OP THE ARTICULAR CARTILAGES. 103 

haps more frequently, where a blister has been long kept open 
by means of the savine cerate; and here, if the blister be of a 
large size, the recurrence of the pain is usually attended with a 
quick pulse, and a furred tongue, and much constitutional irri- 
tation; of all which the patient is relieved, when the blistered 
surface is allowed to skin over. It is evident that it is of much 
importance, and also that it may require considerable discrimi- 
nation on the part of the surgeon, to distinguish when the issue 
or the blister begins to be injurious, and ought therefore to be 
persevered in no longer. 

In other instances, where the symptoms have returned un- 
der the use of the caustic issue, it has appeared to me that 
this w T as to be explained in a different manner. A very small 
quantity of matter has been formed by the ulcerated surfaces 
of the joint, but not sufficient to prevent the application of the 
caustic from producing in the first instance very considerable 
benefit. But having once begun, the suppuration has conti- 
nued, until a sufficient quantity of pus has been collected to oc- 
casion distention of the joint, and the reproduction of the for- 
mer symptoms, in spite of the remedy which before relieved 
them. Such cases are not of very unfrequent occurrence, and 
they show that the surgeon should not incautiously give a very 
favourable prognosis in the first instance, because the imme-' 
diate effects of the issue have been beneficial; but that he should 
wait and observe whether these good effects continue, before 
he ventures positively to predict his patient's recovery. 



The treatment of the abscess which arises from this disease 
in a joint, makes a question of very serious importance, but 
more so as it regards children, than adults; since the former 
may, and do frequently, recover, even after an extensive sup- 
puration has taken place; whereas the recovery of an adult per- 
son from an abscess arising out of ulceration of any of the 
textures belonging to a joint is a comparatively rare occurrence. 

I have not found that the method of evacuating the matter, 
which has been recommended by Mr. Abernethy, in his trea- 
tise on the lumbar abscess, is attended with any particular ad- 
vantage in a case of carious joint. Indeed this corresponds 
with what a little consideration might lead us to expect. If 
an abscess takes place as a primary affection, the disease being 



104 ON THE ULCERATION 

confined to the soft parts, there may be nothing to prevent the 
contraction of the cyst, and the gradual diminution of pus 
evacuated at each puncture. But where an abscess occurs, in 
consequence of an ulcerated state of the articular cartilages and 
bones, as the cause of the abscess exists equally after, as before 
the puncture, the suppuration will necessarily be kept up, and 
the contraction of the cyst, and the obliteration of its cavity, 
will be prevented. 

In some instances I have been led to believe, that, after the 
application of the caustic, the tumour formed by the abscess has 
diminished in size; as if from an absorption of a portion of its 
contents. I have, however, seen no instance of complete ab- 
sorption having taken place under this treatment, nor have I 
been more successful in my attempts to procure the absorption 
of an abscess by other means. Emetics, whether they were 
given to excite vomiting, or only in nauseating doses, were, in 
my experiments, of no service. Electricity was never useful; 
appearing rather to occasion a more rapid accumulation of mat- 
ter. It being supposed, that pressure, under certain circum- 
stances, causes an increased action of the absorbent vessels, in 
two cases I applied stripes of adhesive plaster round the limb, 
with the view of trying the effects of pressure on the contents 
of the abscess. The consequence was, a speedy diminution of 
the external tumour; but I afterwards found that this arose, 
not from any absorption having taken place, but simply from 
the increased resistance on the surface causing the abscess to 
occupy a larger space in the interior of the limb. Yet I do not 
feel myself justified in asserting, that there is no such, thing as 
the spontaneous cure of an abscess by absorption. I have cer- 
tainly seen several instances of tumours, having all the external 
characters of abscess, which, in the course of a few months, 
and sometimes in a much shorter space of time, have wholly dis- 
appeared. The question, however, will always remain, whe- 
ther such a tumour was really an abscess, or simply a collection 
of serum. A young woman was admitted into St. George's 
Hospital, having a tumour containing fluid, tender to the touch, 
and with the skin over it inflamed, on the anterior part of 
the pectoral muscle, near the axilla. Not doubting that it was 
an abscess, I punctured it with a lancet, and a considerable 
quantity, not of pus, but of pure serum, escaped. Some time 



OF THE ARTICULAR CARTILAGES. 105 

afterwards a similar tumour presented itself in the neighbour- 
hood of the former one, which I did not puncture, and this dis- 
appeared spontaneously, without discharging its contents. If 
I had not punctured the first tumour, 1 might probably have re- 
garded each of them as affording an example of an abscess 
having been removed by absorption. 

The early puncture of an abscess connected with a diseased 
joint is certainly not to be recommended. I have always ob- 
served that such an abscess has healed more readily, and that the 
opening of it, (whether by a natural process, or by the lancet) 
has been attended with fewer ill consequences, where the patient 
has been kept for some time in a state of perfect quietude, and the 
other methods of treatment, formerly mentioned, have been pre- 
viously resorted to, than where it has taken place immediately on 
the patient coming under the care of the surgeon. Nor is this 
difficult to explain: in the latter case, at the bottom of the ab- 
scess there is a carious or ulcerated surface of bone; in the for- 
mer, it is highly probable that the process of cure has already 
begun, and that where there was diseased bone before, there is 
now a granulating surface. At any rate it cannot be supposed, 
that when, in consequence of the neglect of the disease, the ul- 
cerated bones, as well as the other parts, are in a state of in- 
flammation, the abscess can be under such favourable circum- 
stances for being opened, as when such inflammation has been 
previously allowed to subside, under rest, and the employment 
of proper remedies. 

An abscess connected with any joint, but particularly one 
connected with the hip, does not form a regular cavity, but 
usually makes numerous and circuitous sinuses in the interstices 
of the muscles, tendons, and fasciae, before it presents itself un- 
der the integuments. It is therefore less easy to evacuate its 
contents, than those of an ordinary lumbar abscess; and indeed 
it can seldom be emptied, without handling and compressing 
the limb, in order to press the matter out of the sinuses, in which 
it lodges. But this is often attended with very ill consequences. 
Inflammation takes place of the cyst of the abscess, and pus is 
again very rapidly accumulated. Small blood-vessels give way 
on its inner surface, the bloody discharge of which, mixed with 
the newly-secreted pus, goes into putrefaction, and exceedingly 
disturbs the general system. I have seen cases, where, after a 
10 



106 ON THE ULCERATION 

great deal of pains having been taken to obtain the complete 
evacuation of the contents of the abscess, and the puncture 
having healed, in a few days the tumour has become as large as 
ever, attended with pain in the limb, and a fever resembling 
typhus in its character, and threatening the life of the patient. 
A second puncture having been made, a quantity of putrid 
fetid pus, of a reddish brown colour, has escaped; the confine- 
ment of which had produced all the bad symptoms, which have 
been immediately relieved by its evacuation. 

The practice, which has appeared to me to be, on the whole, 
the best, is the following. An opening having been made with 
an abscess lancet, the limb may be wrapt up in a flannel wrung 
out of hot water, and this may be continued as long as the mat- 
ter continues to flow of itself. In some instances, after a short 
time, the discharge ceases; the orifice heals, and the puncture 
may then be repeated some time afterwards; but where the 
puncture has not become closed, I have never found any ill 
consequences to arise from its remaining open. On the con- 
trary, I have no doubt that it is desirable that the wound should 
not heal until the abscess has contracted, granulated, and healed 
from the bottom; and this is one reason for making, not a small 
puncture, but a free opening with an abscess lancet or double- 
edged scalpel. Another reason for proceeding in this manner 
is that, where the puncture is small, the abscess cannot dis- 
charge the whole of its contents. Wherever this happens, the 
suppuration is much greater than it would have been if the 
matter could have flowed out as fast as it was secreted. A pro- 
fuse discharge from an abscess is an almost certain indication 
that there is a lodgment of matter in some part of its cavity. 
Such a lodgment produces an effect on the secreting surface of 
an abscess, similar to that which a pea produces in an issue, and 
it should, if possible, be prevented. 

I have already observed that the prognosis, which the sur- 
geon is led to form, must depend very much on the circum- 
stance of suppuration having, or not having, taken place. The 
formation of even the smallest quantity of pus in the joint, in 
cases of this disease, very much diminishes in the young per- 
son and still more in the adult, the chance of ultimate recovery. 
On the other hand, where abscess has not begun to form, there 
is perhaps no disease, among those which come under the care 



OF THE ARTICULAR CARTILAGES. 107 

of the surgeon, in which he can employ his art with a better 
prospect of success than this. It is to be observed, however, 
that the symptoms may be relieved, while there are still some 
remains of the disease: or, at any rate, while there is still a dis- 
position to relapse; and in order that the cure should be per- 
manent, it is necessary that the treatment should be employed 
for some time after the patient is apparently recovered. A % 
gentleman who had long laboured under ulceration of the car- 
tilages of the hip, finding himself to be free from all uneasiness, 
allowed the issue to be healed. This was attended with no im- 
mediate ill consequences; but in the course of two or three 
months he began to experience the well-known symptoms of 
his former complaint. A caustic issue w T as again made, and he 
was again relieved. The issue was kept open for twelve 
months longer, and then healed. When I last saw him, two or 
three years after the healing of the issue, he continued perfectly 
well. This, however, is only one of many cases, which might 
be quoted in proof of the above observation. 



When the ulceration of the cartilages has made very consi- 
derable progress, if the patient recovers, so as to preserve the 
limb, he seldom has the use of the joint afterwards, the bones 
composing it being united by anchylosis; but if it has been 
checked in a less advanced stage, even though there may be rea- 
son to believe that the cartilages have been extensively de- 
stroyed, the patient may retain the natural motion of the joint. 
Cases will be found in other parts of this volume, in which the 
bony surfaces of a joint were covered by a dense membrane, 
formed to supply the place of the cartilage which had been de- 
stroyed; and I cannot assert that this membrane is never ulti- 
mately converted into the true cartilaginous structure. In other 
instances a compact layer of bone is generated on the carious 
surface, nearly similar to what is seen in the healthy bone, after 
the cartilage has been destroyed by maceration. I have many 
times, in dissection, observed a portion of the cartilage of a 
joint wanting, and in its place, a thin layer of hard, semi-trans- 
parent substance, of a gray colour, and presenting an irregular 
granulated surface. It is probable that in these cases also the 
original disease had been ulceration of the cartilages. In a 
subject in the dissecting room, I found no remains of cartilage 



108 ON ULCERATION OF THE 

on the bones of one hip; but, in its plac,e, a crust of bony mat- 
ter, of compact texture, of a white colour, smooth, and having 
an appearance not very unlike that of polished marble. Of 
course, in this instance, I could learn nothing of the history of 
the disease: but I suspected that it had been originally one of 
ulceration of the articular cartilage, and this opinion seemed to 
derive confirmation from the following case, which occurred 
afterwards. 

CASE XLI. 

A woman, thirty-six years of age, was admitted into St. 
George's Hospital, with pain in the hip and knee on one side. 
The nates were wasted and flattened, and a large abscess had 
burst, leaving a sinus communicating with the hip-joint. She 
was affected with hectic fever, and gradually sunk and died. 

On inspecting the body, various sinuses were found in the 
neighbourhood of the hip, and communicating with it. 

The synovial membrane and capsular ligament had under- 
gone no alteration in their appearance, beyond what evidently 
depended on the abscess. The cartilage w T as every where ab- 
sorbed from the articulating surfaces, and in its place there was 
a white polished surface, similar to that which has been just 
described. 



SECTION IV. 

CASES OF THIS DISEASE. 

The following cases, which are taken from many similar, of 
w r hich I have preserved notes, are intended to illustrate the ob- 
servations contained in the last two sections. There seems to 
be no doubt that the disease was ulceration of the articular car- 
tilages, since the symptoms exactly corresponded with those 
which have been observed in cases of this description, in which 
an opportunity occurred of examining the morbid appearances 
after death, or after amputation. It will be observed, that I 
have not selected cases in which the disease was situated in the 
hip; nor those in which it had reached its most advanced 
stages; my reasons for which have been, that a sufficient num- 



OF THE ARTICULAR CARTILAGES. 109 

ber of examples of this affection of the hip, may be found among 
the cases already published by Mr. Ford, and other writers; 
and that it is in its early stage that the disease principally de- 
serves to be studied, and that the diagnosis is of the most im- 
portance. 

CASE XLII. 

Mary Jenkins, twenty-one years of age, in May, 1809, re- 
ceived a blow on one of her knees. Soon afterwards, she was 
seized with pain in the joint, which gradually became more se- 
vere. In September of the same year, she was admitted into 
St. George's Hospital on account of this, and of some other 
complaints, which required medical treatment. At first she 
was under the care of Dr. Bancroft. On the 9th of November, 
she came under the care of the surgeons. At this time, the 
knee was somewhat swollen; the swelling having the form of 
the articulating ends of the bones, and appearing greater than it 
really was, on account of the wasting of the muscles of the limb. 
No fluid was perceptible in the joint. She complained of vio- 
lent pain, which she referred chiefly to the inside of the head 
of the tibia, and which was extremely aggravated by motion. 
There was no redness of the skin. She was emaciated, and la- 
boured under a slight degree of hectic fever. 

An issue was made with caustic on each side of the liga- 
ment of the patella. The issues were kept open by means of 
peas; their surfaces being also rubbed with caustic every fourth 
day. 

At the expiration of a fortnight the pain was very much 
abated; she was able to give some motion to the joint without 
much uneasiness. The swelling had nearly disappeared. 

In a short time the pain was completely relieved; however, 
she did not quit the hospital until the September of the follow- 
ing year. At this time she was free from all bad symptoms, 
and had recovered the perfect use of the joint. 

CASE XLI1I. 

• John Reade, twenty-eight years of age, applied for relief as 
an out-patient, of St. George's Hospital, on the 4th of October, 
1811. 

He said, that for the two preceding years he had been sub- 
ject to pains in the elbow, which were occasionally severe, but 

10* 



110 ON THE ULCERATION 

attended with little or no swelling. At the time of his coming 
to the hospital, the pain in the joint was very violent, particu- 
larly at night, when it continually roused him from his sleep. 
There was also pain in the shoulder and wrist; but trifling, 
when compared to that in the elbow, and only occasional. The 
elbow was slightly swollen, the swelling having the form of the 
articulating ends of the bones, and arising, not from fluid within 
the joint, but from inflammation having extended to the cel- 
lular membrane external to it. The fore-arm was kept bent, 
and all attempts to move it from this position caused a severe 
aggravation of the symptoms. There was some degree of symp- 
tomatic fever. 

Eight ounces of blood were taken from the other arm, which 
occasioned some, but not considerable relief. 

October 8th. A caustic issue was made on each side of the 
joint. 

October 11th. He was free from the symptomatic fever; the 
pain in the shoulder and wrist had entirely left him; that in 
the elbow was much diminished. 

October 16th. The sloughs were separated. The issues were 
afterwards kept open by the occasional application of caustic. 
He now made very little complaint of pain, and slept well at 
night. From this time he experienced very little uneasiness. 
He gradually recovered the use of the elbow; and, in a few 
weeks, finding no inconvenience from the complaint, he ceased 
to attend at the hospital. 

CASE XLIV. 

A lady, thirty-three years of age, in November, 1816, first 
experienced a pain in the articulation of the lower jaw, on the 
left side; and this was attended with a sense of stiffness, and 
difficulty of taking and masticating food. Some liniments were 
used, which seemed rather to aggravate the complaint, and were 
therefore left off. From this time the symptoms gradually and 
slowly increased; and, in May, 1818, when I was consulted, 
they were as follow: — There was severe pain in every motion 
of the lower jaw, especially in masticating the food and yawn- 
ing. The pain was induced whenever pressure was made in 
the situation of the articulation of the lower jaw with the left 
temporal bone; but there was no tenderness in any other situa- 



OF THE ARTICULAR CARTILAGES. 1H 

tion. From this joint, however, as from a centre, the pain ex- 
tended in various directions; to the temple; to the back of 
the head, towards the lambdoidal suture; to the lower part 
of the orbit of the left eye, and even down the left arm. She 
said that it was impossible to describe the character of the pain, 
as she had experienced nothing like it before. When the 
fingers were applied to the joint, and the lower jaw was at the 
same time opened and shut, a grating sensation was communi- 
cated to them, as if the articulating surfaces were deprived of 
their cartilages. There was no evident tumefaction. The pa- 
tient did not complain of her sleep being much disturbed; nor 
did her general health appear to be considerably affected, though 
her pulse was as frequent as 96 in a minute. 

The caustic potash was applied so as to make a slough of the 
skin below the ear, opposite the condyle of the lower jaw, on 
the anterior edge of the sterno-cleido-mastoideus muscle. She 
now returned into the country, where she was under the care 
of Mr. Pitman, of Andover, who removed the slough made by 
the caustic, and kept open the issue in the usual manner. 

After the issue had been established for five or six months, 
and not before, there was considerable relief from pain. On 
the 21st of August, 1822, Mr. Wm. Pitman wrote me the fol- 
lowing account of our patient: — "At this time she has the per- 
fect motion of the jaw, but there is still the same grating sensa- 
tion when it is moved as there was formerly, though in a less 
degree. She has the power of masticating almost all articles of 
diet, which are not very hard. The condyle does not appear 
to be much reduced in size; when, however, the mouth is 
widely opened, as in yawning, our patient generally places her 
hand to support the jaw, as if fearful that it might slip out of 
its situation. With all this amendment, however, there is con- 
siderable pain occasionally; and as there has never been an ab- 
solute cessation of pain for more than three or four weeks at a 
time, the issue is still kept open." 

CASE XLV. 

A gentleman, twenty-four years of age, about the end of the 
year 1816, became affected with a slight pain in the left ankle; 
and he observed also that this pain was particularly aggravated 
whenever any thing occurred to press the articulating surfaces 



112 ON THE ULCERATION 

of the joint against each other; for example, when he happened 
to tread with his heel on any projecting stone in the street. 
He also observed a very slight degree of puffy swelling on the 
anterior and outer part of the joint, before the external mal- 
leolus. 

On the 6th of January, 1817, he went to a ball, and danced; 
and on the following day the pain was very much aggravated. 
The exercise also brought on some degree of general tumefac- 
tion about the joint; which, however, subsided with rest, in the 
course of twenty-four hours. But the pain continued and in- 
creased ; so that he could not support the weight of his body 
on that foot, and he was compelled to walk with the assistance 
of one, and afterwards of two, sticks. In May following, a ge- 
neral puffy swelling took place round the whole joint, which 
did not subside. 

On the 30th of June, 1817, he consulted me, being then in 
the following condition: — 

There w 7 as some degree of general cedematous tumefaction 
of the whole joint, in consequence of slight inflammation of the 
cellular membrane external to it. There was a constant and 
severe pain referred to the ankle, which was rendered more 
violent, when he attempted to stand, and when the cartilaginous 
surfaces were pressed against each other, by the hand placed 
on the lower part of the heel. His rest was disturbed at night, 
by painful startings of the limb. 

He had come to consult me at my own house; and in going 
home, he fell from his horse, and wrenched his ankle, which 
brought on inflammation, and rendered all the symptoms still 
more severe. 

He was directed to remain at home, in a state of perfect 
quietude, and never to place the foot on the ground. leeches 
and cold lotions were applied, and the application of the leeches 
was repeated. Under this treatment the additional inflamma- 
tion induced by the accident subsided; and the pain became 
much less severe. At the end of August, a blister was applied 
on each side of the ankle, and kept open by means of the sa- 
vine cerate. After the first blisters were healed, others were 
applied, and kept open in the same manner; and in the inter- 
vals between the applications of the blisters the joint was bound 
up in stripes of linen spread with soap plaster. 



OF THE ARTICULAR CARTILAGES. 113 

About the end of September he was so much relieved that 
(having some concerns which it was of much importance to 
himself to attend to,) he was allowed to go out occasionally in 
a chaise. 

On the 20th of December, a caustic issue was made behind 
the inner ankle. This occasioned exceeding irritation and un- 
easiness, and the issue was in consequence allowed to begin to 
heal, about a fortnight after the separation of the slough. He 
was, however, much benefited by the issue; and after it was 
healed, he was free from pain, and the swelling had subsided. 

On the 23d of May, 181S, he was in the following condition: 
He was free from all pain; could bear the joint to be moved, 
and could support the weight of the body on that foot without 
inconvenience. There was still some slight remains of the 
external swelling. When the joint was moved, a grating sound 
could be heard; and if at this time the fingers were applied to 
the joint, a sensation was communicated to them, as if two hard 
and rough surfaces were rubbed one against the other. 

CASE XLVI. 

Mary Taylor, fifty years of age, was admitted into St. George's 
Hospital, on the 3d of December, 1809. 

She said, that in the preceding July she experienced a vio- 
lent wrench of the right shoulder, in consequence of her hus- 
band having pulled her by the arm. Soon afterwards she was 
attacked with pain in this joint, which gradually became very 
severe. At the time of her admission into the hospital, there was 
no alteration in the external appearance of the shoulder. There 
was not the smallest evident swelling; but she complained of 
constant and violent pain, which was much aggravated by every 
attempt to move the arm. The pain was most severe at night, 
so as very much to disturb her rest. She was unable to lie on 
the side on which the disease w T as situated. 

The arm was supported by a sling, and a blister was applied 
to the shoulder, and afterwards kept open by means of savine 
cerate. 

In less than a fortnight the symptoms were much relieved. 
In the beginning of January, 1810, she had very little pain, 
and slept well at night. About the middle of February she 
was dismissed from the hospital, being free from all her formei 



114 ON THE ULCERATION 

symptoms. She was directed to attend as an out-patient, that 
the blister might be kept open for some time longer; however, 
she never made her appearance at the hospital again, probably 
in consequence of her finding no inconvenience from the com- 
plaint, and of her not being convinced of the necessity of con- 
tinuing the treatment after the symptoms were relieved. 



The following case is of considerable interest, inasmuch as it 
exhibits the disease in its acute form, attended with more ur- 
gent symptoms than those which usually mark its existence in 
the beginning: and also on account of the manifest resemblance 
which it bears to the case of Holder, in which the opportunity 
occurred of examining the state of the diseased parts. 

CASE XLV1I. ■ 

Sarah Hansel!, forty-six years of age, was admitted into St. 
George's Hospital, on the 22d of August, 1822. 

She laboured under pain in the left knee, and a swelling ex- 
tending up the lower part of the thigh, chiefly on the anterior 
part. There was no effusion of fluid into the joint. The leg 
was bent at an acute angle w T ith the thigh, and the patient was 
unable either to extend it, or bend it farther. The pain in the 
knee was referred chiefly to the inside of the joint; it was very 
severe, especially at night, when it awoke her from sleep with 
startings of the limb. Every attempt to press the articulating 
surfaces of the joint against each other was productive of acute 
suffering, causing the patient to scream; and she could not even 
bear the weight of the bed-clothes on the limb. There was 
much symptomatic fever, with a countenance expressive of se- 
vere suffering. The tongue was white and dry, and the pulse 
small and frequent. 

Eleven weeks previous to her admission, she had become 
affected with rheumatic pains in her wrists and ankles. In the 
course of a few days these pains subsided, but she was now 
suddenly seized with most severe pains in the left knee, ac- 
companied by much fever. After two or three days more, the 
joint appeared to be swollen, first on the inside, then in front 
on each side of the ligament of the patella. The swelling at- 
tained a considerable size, but gradually diminished on the ab- 
straction of blood by leeches and cupping. The pain, however, 
became progressively more severe. 



4 

OF THE ARTICULAR CARTILAGES. 115 

She had been always subject to rheumatism; independently 
of which her health was good. The catamenia had ceased since 
the beginning of the attack. 

August 24. She was directed to take two grains of calomel 
and half a grain of opium, in a pill, three times daily. Leeches 
were applied to the knee, and afterwards a blister. 

August 30. The gums were affected by the mercury. The 
pain in the knee was much abated, and she slept better at night. 
General health much improved. She was directed to take a 
pill only twice daily. 

September S. The pain and swelling of the knee were 
much farther diminished. The gums continued sore. A blister 
was applied to the lower part of the thigh. 

September 12. The mercurial pills were discontinued. Ten 
grains of the pulvis ipecacuanha compositus were ordered to be 
given every night, and an issue was made with caustic; one 
above and the other below* the knee joint. The application of 
the caustic gave much immediate relief. 

September 22. The pain was trifling, except when the joint 
was moved: and there were still some painful startings of the 
limb at night. The swelling was reduced, so that the joint 
had become of its natural size and figure. Her general health 
was much improved. 

October 6. The symptoms were still farther relieved, and 
the leg was gradually becoming more extended. The issues 
were kept open by the occasional application of the caustic 
potash. From this time her amendment was progressive. On 
the Sth of May, 1833, she quitted the hospital, the knee being 
anchylosed in the bent position. She still experienced slight 
pain occasionally in it. 

I have before observed, that ulceration of the articular carti- 
lages is not unfrequently complicated with inflammation of 
the synovial membrane. Sometimes the one, and sometimes 
the other is the original disease; in like manner as we find ulcer 
of the cornea of the eye, in some cases the cause, and in others 
the consequence, of inflammation of the tunica conjunctiva. 
In the very advanced stage, when the organization of the joint 
is completely destroyed, this complication must always exist: 
and it is unnecessary to adduce evidence of this fact. But oc- 



116 ON THE ULCERATION 

casionally the two diseases are combined together in a more 
early stage, and previous to the establishment of suppuration. 

The two following cases will serve to illustrate these obser- 
vations. In one of them the ulceration of the cartilages appears 
to have been the primary, and inflammation of the synovial 
membrane the secondary, affection: at least the symptoms 
which occurred seem to be better explicable on this supposition 
than on any other. In the second case, the early symptoms 
indicated the existence of inflammation of the synovial mem- 
brane, and it was not until after these had subsided that there 
were any signs of ulceration of the cartilages. 

CASE XLVIII. 

John Child, thirty-three years of age, in April, 1814, was 
seized with a pain in one knee. The pain at first was slight, 
but gradually became very severe. It was referred principally 
to the head of the tibia on each side of the ligament of the pa- 
tella. At the end of five months, the joint for the first time 
became swollen, and the swelling soon attained a considerable 
size. He was now under the necessity of confining himself to 
his room. Five blisters were applied in succession, and the 
swelling and pain subsided; so that at the end of three weeks 
he returned to his usual occupations. In five or six days, how- 
ever, the pain and the swelling returned, and he was in conse- 
quence admitted into St. George's Hospital on the 26th of 
October. 

At this time he complained of pain in the joint, referred to 
the head of the tibia, on each side of the ligament of the patella. 
The pain was excruciating, so as often to keep him awake 
during the whole night. The knee was much swollen: the 
swelling arising from an effusion of fluid into its cavity, and 
having the same form as in ordinary cases of inflammation of 
the synovial membrane. 

October 29. A blister was applied including the greater 
part of the circumference of the joint. 

November 7. The swelling and pain were relieved. Ano- 
ther blister was applied, which was kept open with the savine 
cerate until the end of the month. It was then healed, and a 
third blister was applied and kept open in the same manner. 

On the 21st of December he left the hospital of his own ac- 



OF THE ARTICULAR CARTILAGES. 117 

cord. The pain at this time was very nearly, but not com- 
pletely, relieved: the knee was swollen only in a very slight 
degree; and the trifling swelling which remained appeared to 
arise, not from fluid within the articulation, but from thick- 
ening of the soft parts in consequence of their having been 
previously inflamed. 

CASE XL1X. 

Anne Donegan, twenty-seven years of age, was admitted 
into St. George's Hospital in May, 1817, labouring under a 
disease of one knee. 

The leg was bent at a right angle with the thigh, and the 
patient was incapable of altering its position. There was no 
effusion of fluid into the cavity of the joint, but there was a 
slight degree of swelling, apparently in consequence of an effu- 
sion of fluid into the cellular texture external to it. The joint 
was painful, and tender to the touch. 

From the history of the case, it appeared that the disease had 
originated in an attack of inflammation of the synovial mem- 
brane, which had subsided and left the present symptoms. 

Leeches were applied to the knee, and the limb was kept in 
a state of repose. In the beginning of June, there was a severe 
aggravation of the pain in the knee, and the leg became more 
bent, so as to make an acute angle with the thigh. 

June 7. A blister was applied to the thigh immediately above 
the knee, and arf opiate was directed to be taken at bed-time. 

The pain w r as at first relieved by the application of the blis- 
ter; but, on the 12th of June, it became again as severe as ever. 

Another blister was applied on the inside of the knee, and 
directed to be kept open with the savine cerate. 

June 18. The pain in the knee was excruciating: the leg 
continued bent at an acute angle with the thigh. The blister 
being healed, an issue was made with caustic on the inside of 
the joint. 

The pain was much relieved immediately after the applica- 
tion of the caustic. 

July 8. The pain in the knee, which had become much abated, 
being again severe, another issue was made with caustic over 
the outer condyle of the femur. 

From this time the pain was entirely relieved. The issues 
were kept open. 
11 



118 ON A SCROFULOUS DISEASE 

October 6. The patient continued free from pain, and she 
could move the limb much more freely than before. 

December 16. The motion of the joint was still very limited: 
but there was no pain, except when the leg was moved, so as to 
extend the adhesions which appeared to have been formed in 
the joint. She left the hospital. 



CHAPTER V. 

ON A SCROFULOUS DISEASE OF THE JOINTS HAVING ITS 
ORIGIN IN THE CANCELLOUS STRUCTURE OF THE 
BONES. 



SECTION I. 



PATHOLOGICAL OBSERVATIONS. 



The term scrofula is often employed without much preci- 
sion; and, indeed, it is not always easy to determine what 
symptoms ought, and what ought not, to be^referred to this 
disease. It has been usual to regard nearly all the affections 
of the joints as scrofulous; and I believe it may be found that 
persons having a predisposition to scrofula, are, on the whole, 
more liable than others to those affections, which form the sub- 
ject of the preceding chapters. As, however, they occur very 
frequently w 7 here no such predisposition exists, there seem to 
be no sufficient grounds for considering them as having any 
necessary connexion with it; and it can be no more proper to 
designate these as scrofulous, than it would be to denominate 
inflammation of the synovial membrane a mercurial disease, be- 
cause it occasionally arises from the use of mercury. But 
there is another malady, which affects the joints, having all 
the characters of scrofula: generally occurring in persons who 
have a scrofulous appearance, and usually preceded by, or com- 
bined with, other scrofulous symptoms. 



OF THE JOINTS. 119 

In this disease of the joints, the cancellous structure of the 
bones is the part primarily affected; in consequence of which, 
ulceration takes place in the cartilages covering their articu- 
lating surfaces. The cartilages being ulcerated, the subsequent 
progress of the disease is in many respects the same as where 
the ulceration takes place in the first instance. 

CASE L. 

Thomas Scales, aged eighteen, having a scrofulous appear- 
ance, was admitted into St. George's Hospital on the 18th of 
October, 1815. 

He complained of pain, which he referred to the inside of 
one foot. The pain was constant, but slight, and not sufficient 
to prevent his walking as usual. There was very little, if any, 
tumefaction, and the parts were not tender to the touch. He 
was also in a general ill state of health: there were symptoms of 
derangement of the functions of the liver, and the urine was tur- 
bid, depositing a quantity of sediment, which stained the vessel 
that contained it of a pink colour. He was heavy and stupid, 
and scarcely able to give any consistent account of his ailments. 
There were some small ulcerations at the edges of his eyelids. 
While he was under a course of remedies for these com- 
plaints, he was seized, in the beginning of February, 1816, 
with a continued fever, of which he died on the 1st of March. 
On dissection, the foot, which had been the seat of the pain, 
was. particularly examined. The bones of the tarsus, and me- 
tatarsus, were found to contain an unusually small quantity of 
earthy matter; so that they were preternaturally soft, and ad- 
mitted of being cut in any direction with a scalpel, without 
turning its edge. The cut surfaces of these bones were of a 
deep red colour, in consequence of increased vascularity; and 
vessels injected with their own blood could be distinctly traced 
extending from the bones into the cartilages covering them, 
and rendering the latter, in a few spots, of a red colour. The 
cartilage covering the internal cuneiform bone where it forms 
the joint with the metatarsal bone of the great toe, was ulce- 
rated to a small extent. The ulceration had begun on that side 
of the cartilage which was connected to the bone; the surface 
towards the joint remaining entire. The bones of the tarsus 
were more diseased than those of the metatarsus; and those on 
the inside of the tarsus were affected in a greater degree than 



120 ON A SCROFULOUS DISEASE 

those on the outside. The bones of the other foot were affected 
in the same manner, but in a much less degree. Some of the 
other bones were examined, and were found nearly in a na- 
tural condition. 

CASE LI. 

December 21st, 1814. In a boy apparently about ten years 
of age, whose body I had the opportunity of examining after 
death, I observed the following appearances: — 

Both elbows were slightly swollen. On the fore-part of the 
right arm, immediately above the elbow, there was the orifice 
of a sinus, w T hich extended downwards obliquely into the can- 
cellous structure of the bone, where it terminated, without 
communicating with the cavity of the joint. The cancellous 
structure of the articulating extremities of the os brachii, ra- 
dius, and ulna, was so soft, that it might be crushed by a very 
slight degree of force when squeezed between the fingers: it 
was of a dark red colour, preternaturally* vascular; and there 
was a- reddish fluid, mixed with medulla, in the cancelli. The 
cartilages covering the radius and ulna were in a natural state; 
that belonging to the os brachii was ulcerated in a few spots on 
the surface towards the bone, while the surface towards the ca- 
vity of the joint was entire. There were no morbid appear- 
ances of the ligaments or synovial membrane. 

The bones of the left elbow w 7 ere in a similar state of disease; 
the cartilages were entirely destroyed by ulceration ; and ca- 
rious surfaces of bone were exposed. A small portion of dead 
bone had exfoliated into the cavity of the joint, where it lay 
surrounded by matter. The synovial membrane and ligaments 
were extensively destroyed, and there were several sinuses 
communicating with the joint and opening externally. 

On examining the right knee, which externally had not the 
slightest marks of disease, and admitted of perfect motion, the 
cancellous structure of all the bones which* enter into its com- 
position was found in the same morbid condition with that of 
the bones of the elbows, being preternaturally red and vascular, 
with a much less proportion than is usual of earthy matter, so 
that they admitted of being crushed by a very slight force. In 
the interior of the lower extremity of the femur, between the 
two condyles, there was one part where the earthy matter 
seemed to have entirely disappeared, and there was in conse- 
quence an irregular space, in w T hich there was little else than 



OF THE JOINTS. 



121 



medulla and a reddish fluid mixed together: near this part, the 
cartilage had only a very slight adhesion to the bone, and ul- 
ceration had begun on its inner surface. 

In several other joints which were examined, there were 
marks of the same disease, but in a less advanced stage. 



CASE LII. 

John King, twenty-six years of age, having blue eyes, thick 
lips, and a florid complexion, was admitted into St. George's 
Hospital on the 1st of June, 1811, on account of a complaint in 
his right ankle and foot. I received the following account of 
his case, partly from himself, and partly from a medical gentle- 
man, who was in the habit of seeing him before he came into 
the hospital. 

About the end of May, 1810, he wrenched his foot. The in- 
step and ankle became swollen and painful, but in a few days 
these symptoms subsided. During the summer he experienced 
slight pain and weakness of these parts, whenever he took more 
than his usual quantity of exercise. In October a slight tume- 
faction was observed on each side of the ankle, and the pain was 
more severe, but still not sufficient to prevent his going about his 
usual occupations. About the middle of December, the pain 
became more violent, and he was confined to the house for a 
fortnight ; after which the pain abated, so that he was able to 
go about with the assistance of a crutch. 

In March, 1811, an abscess burst on the outside of the foot. 
The formation of the abscess was not attended with any conside- 
rable degree of pain. 

He formerly had been supposed to labour under incipient 
phthisis pulmonalis ; but from the time of the disease having be- 
gun in his foot, he suffered no inconvenience from the complaint 
in his lungs. 

At the time of his admission into the hospital, there was a 
diffused oedematous swelling of the soft parts over the whole 
foot and ankle. On the outside there were the orifices of three 
or four sinuses, which had burst at different periods. He had 
very little pain, even on motion or pressure. Soon after his 
admission, another abscess broke on the inside of the heel. 

On the 11th of July the leg was amputated, 

a* 



122 ON A SCROFULOUS DISEASE 

On examining the foot, the cells of the cellular membrane 
were found distended with serum and coagulated lymph. 

All the bones had undergone a morbid change, similar to 
what was observed in the last case, except that they were still 
softer and more vascular. 

The cartilages of the ankle were completely destroyed by 
ulceration, and the exposed surfaces of bone were in a state of 
caries. The cartilages of the tarsus were entire, but, in some 
places, of a red colour; and this was found to arise from vessels 
loaded with red blood, extending into them from the bone. 
The ligaments and synovial membranes of the tarsal joints were 
in a natural state, as were also those of the ankle, except where 
they had been destroyed by the abscesses. 

CASE LIII. 

This patient was a soldier in the Coldstream Guards. I once 
had an opportunity of seeing him before amputation was per- 
formed; and, through the kindness of the medical officers of 
the regiment, I was favoured with the previous history of the 
complaint, and with the opportunity of examining the ampu- 
tated joint. 

William Miles, twenty years of age, of a delicate complexion, 
with red hair and dilated pupils, was attacked with a slight pain 
and swelling of the left knee, about the middle of January, 
1808. On keeping quiet for a few days, the swelling subsided; 
but it returned about the end of March, though still attended 
with very little pain. 

He was received into the hospital of the battalion, at Chat- 
ham; and, on the 9th of June following, he was sent to the re- 
gimental hospital in London. 

At this time the diseased knee measured in circumference 
three inches more than the other. Fluid was felt external to 
the joint, and in the cavity of the joint itself. The leg was 
kept extended, and all attempts to bend it gave considerable 
pain; but otherwise, the pain which he endured was trifling, 
amounting only to a slight degree of uneasiness, deep-seated in 
the joint. On the Sth of July, an abscess burst near the inner 
edge of the patella, and discharged about eight ounces of thin 
pus. On the 27th of July, the limb was amputated. 

On examining the knee, the articulating extremities of the 



OF THE JOINTS. 123 

tibia and fibula were found so soft, that they were readily cut 
by a common knife: they contained much less earthy matter 
than is usual, and their cancelli were filled by a yellow cheesy 
substance. 

The cartilage covering the head of the tibia was destroyed 
by ulceration in a few spots at the margin. That of the femur 
was eroded for a very small extent behind the crucial liga- 
ments. The patella, and the cartilage covering it, were in a 
natural state. Coagulated lymph, having a gelatinous appear- 
ance, had been effused into the cellular texture, on the outside 
of the synovial membrane. Pus was found external to the 
joint, and in the joint itself. 

CASE LIV. 

Charles Miller, twenty years of age, having blue eyes, light 
hair, and a fair complexion, was admitted into St. George's 
Hospital, in April, 1S08, on account of a disease of one foot. 

The whole foot was swollen and oedematous, with two fistu- 
lous sinuses, one on the inside, and the other on the outside, 
through which a small quantity of scrofulous matter was dis- 
charged. A probe having been introduced into either of these 
sinuses, some exposed pieces of bone might be distinguished. 

On the 16th of May, the limb was amputated below the knee. 

On examining the amputated foot the muscles were found 
pale and wasted from want of use, and the cellular membrane 
w r as distended with coagulated lymph. 

The extremities of the tibia and fibula, all the bones of the 
tarsus, and the extremities of the bones of the metatarsus, con- 
tained much less earthy matter than is usual. They were so 
soft, that they might be cut with a scalpel without the edge of 
it being turned. They were preternaturally red and vascular, 
and a yellow cheesy substance was deposited in the cancelli. 
The cartilage at the base of the fifth metatarsal bone was de- 
stroyed by ulceration. Those at the bases of the three middle 
metatarsal bones were also destroyed, and the exposed surfaces 
of bone were dead, and undergoing the process of exfoliation. 
The cartilages of all the other bones were in a natural state. 
Pus and coagulated lymph had been effused in the neighbour- 
hood of the dead and carious bones, and the sinuses communi- 
cated with them. The synovial membrane and ligaments were 
in a natural state, except where destroyed by ulceration. 



124 ON A SCROFULOUS DISEASE 

CASE LV. 

Ellen McMillan, eight years of age, was admitted into St. 
George's Hospital, on the 6th of March, 1833. 

She complained of pain in the right hip, extending down the 
thigh, and much increased by motion, or by pressing the arti- 
culating surfaces against each other. The foot was everted. 
The limb was of its natural length. She had been observed 
to limp in walking about six weeks ago, since which the symp- 
toms had progressively increased. 

In the beginning of April, while under treatment for the 
disease of the hip, she became affected with other symptoms, 
indicating the existence of disease in the brain; under which 
she sank, and died on the 6th of April. 

On examining the body, a scrofulous tubercle was discovered 
in the lower part of the right hemisphere of the cerebrum, and 
the vessels of the brain generally were found to be turgid with 
blood. 

In the right hip, the cartilage of the head of the femur, in 
the neighbourhood of the attachment of the round ligament, 
was found to have been destroyed by ulceration, and of the 
round ligament itself scarcely any vestige remained. The 
cartilage of the acetabulum was also ulcerated to some extent 
at the lower part. The bone of the pelvis, where it forms the 
acetabulum, and the head and neck of the femur, were of a soft 
consistence, so that they could be divided by a knife; and there 
was a considerable deposite of yellow substance in the cancel- 
lous structure of the latter. 

On examining the bones of the left hip, they were found to 
be affected in the same manner as those of the right hip, but 
they were in a less advanced stage of the disease. 

The cartilage of the head of the femur was detached with 
unusual facility from the bone below, the surface of the latter 
presenting a highly vascular appearance; and, in two spots, the 
layer of the cartilage towards the bone was destroyed by ulce- 
ration, while that towards the cavity of the joint remained en- 
tire. The space thus formed between the cartilage and the 
bone was occupied by a vascular substance of the consistence 
of granulations. 

CASE LVI. 

A girl, fifteen years of age, was admitted into St. George's 



OF THE JOINTS. 125 

Hospital, in the winter of 1809, labouring under symptoms of 
disease of one hip, as well as of one elbow. After remaining 
some months in the hospital, she left it of her own accord in 
the beginning of August. In the following October she was 
re-admitted with the disease both of the hip and elbow much 
advanced. There was a large abscess in the thigh; her general 
health was much impaired, and she sank and died in less than 
six weeks after her re-admission. 

On dissection, the abscess in the thigh was found communi- 
cating with the cavity of the hip-joint, through an ulcerated 
opening of the capsular ligament and synovial membrane. The 
cartilages of the hip had entirely disappeared; the bones were 
carious; the acetabulum had been rendered deeper and wider, 
and the head of the femur smaller than natural. The capsular 
ligament and synovial membrane were thickened, and a soft 
organized mass, similar to the substance of adhesions, was found 
adhering to the neck of the femur. The cancellous structure 
of the bones was softer than natural, so that it might be cut 
with a scalpel, or crushed between the fingers; and the appear- 
ance of it in other respects corresponded to that of the diseased 
bones in the cases which have been just related. 

The disease of the elbow was similar to that of the hip-joint; 
but it had made less progress. The ligaments and synovial 
membrane of the elbow were nearly in a natural state, and 
some thin portions of cartilage still remained lying on the sur- 
face of the carious bone, but having little or no adhesion to it. 



The preceding cases sufficiently illustrate the nature and 
progress of this disease. The morbid affection appears to have 
its origin in the bones, which become preternaturally vascular* 
and containing a less than usual quantity of earthy matter; 
while, at first, a transparent fluid, and afterwards a yellow 
cheesy substance is deposited in their cancelli. 

From the diseased bone, we see, in some instances, vessels 
carrying red blood extend into the cartilage. The cartilage 
afterwards ulcerates in spots, the ulceration beginning on that 
surface which is connected to the bone. The ulceration of the 
cartilage often proceeds very slowly. Occasionally a portion 
of the carious bone dies and exfoliates. 

As the caries of the bone advances, inflammation takes place 
of the cellular membrane external to the joint. Serum, and 



126 ON A SCROFULOUS DISEASE 

afterwards coagulated lymph, is effused; and hence arises a 
puffy and elastic swelling in the early, and an cedematous 
swelling in the advanced stage of the disease. Abscess having 
formed in the joint, it makes its way by ulceration through the 
ligaments and synovial membrane, and afterwards bursts exter- 
nally, having caused the formation of numerous and circuitous 
sinuses in the neighbouring soft parts. 

In one of the cases which have been related, thin layers of 
cartilage were found lying on the ulcerated surface of bone, 
apparently unconnected with it. In some instances, in the 
advanced stage of this disease, we find nearly the whole of the 
cartilage forming an exfoliation instead of being ulcerated. 

This scrofulous affection attacks those bones, or portion of 
bones, which have a spongy texture, as the extremities of the 
cylindrical bones, and the bones of the carpus and tarsus; and 
hence the joints become affected from their contiguity to the 
parts which are the original seat of the disease. Sometimes, 
however, we may trace the effects of these morbid changes 
even in the shaft of a cylindrical bone; so that we see the 
femur or tibia converted in its middle into a thin shell of earthy 
matter, enclosing a medullary canal of unusual magnitude. 

It has been remarked by a modern author,* that, in the last 
stage of this disease, the bones not only lose the preternatural 
vascularity which they possessed at an early period, but even 
become less vascular than healthy bone. I believe the obser- 
vation to be correct; and this diminution of the number of 
vessels, and, consequently, of the supply of blood, is probably 
(as this author has suggested) the proximate cause of those ex- 
foliations which sometimes occur where the disease has existed 
for a considerable length of time, especially in the smaller 
bones. 



SECTION II. 

ON THE SYMPTOMS OF THIS DISEASE. 

The scrofulous affection of the joints occurs frequently in 
children : it is rare after thirty years of age. Examples of 
it occur in almost every joint of the body; but some of them, 

* Lloyd on Scrofula, p. 123. 



OF THE JOINTS. 127 

especially the shoulder, appear to be, on the whole, less liable 
to it than many other articulations.* 

As it depends on a certain morbid condition of the general 
system, it is not surprising that we should sometimes find it 
affecting several joints at the same time ; nor, that it should 
show itself in different joints in succession; attacking a second 
joint after it had been cured in the first, or after the first has 
been removed by amputation. It is seldom met with, except 
in persons who have the marks of what is called a scrofulous 
diathesis: and in many cases it is either preceded, attended, 
or followed, by some other scrofulous symptoms; such as en- 
largement of the scrofulous glands of the neck and mesentery, 
or tubercles of the lungs. I have often been led to believe^ 
that the occurrence of this disease in a joint has suspended the 
progress of some other, and, perhaps, more serious, disease else- 
where. 

The scrofulous disease is more likely to be confounded w T ith 
that which formed the subject of the last chapter, than with any 
other. There is, in many respects, a correspondence in their 
symptoms. There are, however, certain points of difference; 
and I believe that this difference will be found, in general, suf- 
ficient to enable the practitioner, who is careful and minute in 
his observations, to make a correct diagnosis; at least, in those 
cases in which the local disease is not so far advanced, and in 
which it has not so much affected the general constitution, as 
to make the diagnosis of little real importance. 

While the disease is going on in the cancellous structure oi 
the bones, before it has extended to the other textures, and 
while there is still no evident swelling, the patient experiences 
some degree of pain; w 7 hich, however, is never so severe as to 
occasion serious distress, and often is so slight, and takes place 
so gradually, that it is scarcely noticed. 

After a time (which may vary from a few weeks to several 
months,) the parts external to the joint begin to sympathize 
with those within it; and serum and coagulated lymph being 

* Perhaps this arises from the circumstance of the shoulder being less ex- 
posed to the influence of the external cold, which, in most instances, promotes 
the development of scrofulous diseases. So we find the scrofulous enlarge- 
ment of the lymphatic glands to occur more frequently in the neck than in 
the groin or axilla; which last are generally protected by a warmer clothing. 



128 ON A SCROFULOUS DISEASE 

effused into the cellular membrane, the joint appears swollen. 
The swelling is puffy and elastic, and though usually more in 
degree than it is at the same period in those cases in which 
the ulceration of the cartilages occurs as a primary disease, it 
is not greater in appearance, because the muscles of the limb 
are not equally wasted from want of exercise. I have observed 
that, in children, the swelling is, in the first instance, usually 
less diffused, and somewhat firmer to the touch, than in the 
adult. 

If a suspicion of some disease of the joint has not existed 
previously, it is always awakened as soon as the swelling has 
taken place. Should the patient be a child, it not uncommonly 
happens that the swelling is the first thing, which the nurse or 
the parents discover. This leads to a more accurate inquiry, 
and the child is observed to limp in walking, if the disease be 
in the lower limb, and to complain of pain on certain occasions. 

I have said, that the swelling is puffy and elastic; and, after 
what has been remarked in the former chapters, it is needless 
to point out mor6 particularly the difference between it and 
the swelling, which takes place in cases of inflamed synovial 
membrane. The swelling increases, but not uniformly, and it 
is greater after the limb has been much exercised than when 
it has been allowed to remain for some time in a state of quie- 
tude. 

As the cartilages continue to ulcerate, the pain becomes 
somewhat, but not materially, aggravated. It is not severe 
until abscess has formed, and the parts over the abscess have be- 
come distended and inflamed. The skin, under these circum- 
stances, assumes a dark red or purple colour. The abscess is 
slow in its progress: when it bursts, or is opened, it discharges 
a thin pus, with portions of curdly substance floating jn it. Af- 
terwards the discharge becomes smaller in quantity, and thicker 
in consistence, and at last it nearly resembles the cheesy matter 
which is found in scrofulous absorbent glands. 

In most instances, several abscesses take place in succession, 
but at various intervals; some of which heal, while others re- 
main open, in the form of fistulous sinuses, at the bottom of 
which carious bone may be distinguished by means of a probe. 

The disease not unfrequently remains in this state for several 
months, or even for a much longer period, without the consti- 



OF THE JOINTS. 129 

iution being materially disturbed by it. In the less fortunate 
cases, the patient at last becomes affected with a hectic fever, 
under which he gradually sinks, unless the cause of it be re- 
moved by amputation. At other times, a curative process be- 
gins; the sinuses close; the oedema subsides; and the patient 
ultimately recovers, either with or without an anchylosis, ac- 
cordingly as more or less destruction of the articulating surfaces 
has taken place. But the cure is always tedious, unless the dis- 
ease has been arrested at a very early period. It is not un- 
common to see a patient with a scrofulous joint, in a state of 
imperfect anchylosis, with a single sinus remaining open, and 
waiting for many years before even such a cure as anchylosis 
affords, can be said to be completed. The chance of ultimate 
recovery is not the same in every articulation; and I have ob- 
served that it is much less where the disease attacks the com- 
plicated joints of the carpus and tarsus, than when it is situated 
in those which, though of a larger size, are of a more simple 
structure. 

The principal difference w T hich is to be observed between the 
symptoms, which have been just described, and those which 
are met with where ulceration of the cartilages occurs as a pri- 
mary affection, is in the degree of pain which the patient en- 
dures, and which is much less in the cases of the former than 
in those of the latter description. 

It may, indeed, be a matter of surprise that, in cases of this 
scrofulous affection, the sufferings of the patient should be so 
little as they are found to be, in proportion to the quantity of 
local mischief. For the most part, the pain which he expe- 
riences is not a subject of serious complaint, except at the time 
when an abscess is just presenting itself underneath the skin; 
and then it is immediately relieved by the abscess bursting. 
There is not that severe pain, which exhausts the powers and 
the spirits of the patient, in cases of ulceration of the cartilage, 
arising from other causes, except in a very few instances, and 
in the most advanced stage of the disease, when a portion of 
the ulcerated bone has died, and, having exfoliated. so as to lie 
loose in the cavity of the joint, irritates the parts with which 
it is in contact, and thus becomes a source of constant torment. 

There are other circumstances besides the less degree of pain, 
which, although not in themselves sufficient, it is useful to take 
12 



130 ON A SCROFULOUS DISEASE 

into the account in forming our diagnosis; such as the general 
aspect and constitution of the patient, and his having manifested 
a disposition to other scrofulous symptoms; the very tedious 
progress of the disease; and the circumstance of the suppuration 
not being in general confined to a single collection of matter, 
but producing a succession of abscesses. 

The progress of this disease in the hip very much resembles 
that of the disease, which was described in the last chapter. 
Whatever pain exists is referred to the knee rather than to the 
joint actually affected. There is the same alteration in the ap- 
pearance of the nates; the same apparent elongation of the limb 
in the early stage; and the same shortening of it at a more ad- 
vanced period. Dislocation occasionally takes place in the di- 
rection upwards and outwards: in one instance only I have 
seen it in the direction forward, the head of the femur resting 
on the pubes, and the knee and toes being turned outwards. 
The shortening of the limb, whether it be from destruction of 
bone or actual dislocation, is followed, as in other cases of dis- 
eased hip, by the formation of abscesses, which present them- 
selves in the usual situations. Yet, notwithstanding all these 
points of resemblance, attention to the points which have been 
already noticed, and especially to the quantity of pain, which 
the patient has endured, will, for the most part, enable us to dis- 
tinguish the real nature of the case. A girl laboured under an 
affection of the hip-joint, in which the nates were flattened, the 
limb had become shortened, and an abscess had broken on the 
outside of the thigh; but it was observed that she had suffered 
comparatively little pain. Under these circumstances she died ; 
and when I was about to examine the body, I observed to those 
who were present, that there was little doubt but that the origin 
of the disease would be found to have been, not in the cartilages, 
nor in the bony surfaces to which they are connected, but in 
the cancellous structure of the bone. The appearances which 
were observed justified this remark. The cartilages were ul- 
cerated, and the bones themselves destroyed to some extent. 
The latter were soft, so that they might be cut with a scalpel; 
and, on dividing the articulating extremity of the femur*longi- 
tudinally, a considerable collection of thick pus was found in 
the neck of that bone, below the head, which either had not 
escaped at all, or had escaped in very small quantity, by oozing 



OP THE JOINTS. 131 

through the cancelli, which were interposed between it and the 
cavity of the hip-joint 

When the disease occurs in those joints which are more su- 
perficially situated, such as the knee and ankle, we may be 
farther assisted in our diagnosis by observing the character of 
the swelling by which it is accompanied, and which is some- 
what peculiar, especially in children, previously to the forma- 
tion of abscess. It is then limited to the immediate vicinity 
of the affected part, and has a not ill-defined margin. When 
the disease is in the knee, the child usually keeps the leg a good 
deal bent, and the condyles of the femur are seen projecting, of 
a somewhat globular form, and appearing as if they were ac- 
tually enlarged, although we know them to be not enlarged in 
reality. Altogether, however difficult it may be to describe it 
in words, the appearance is very characteristic; so that, judg- 
ing from it alone, an experienced surgeon will, in many in- 
stances, be able at once to form a correct diagnosis. 



SECTION III. 



ON THE TREATMENT. 



In attempting the cure of the scrofulous disease of the joints, 
it is necessary to bear in mind, that it depends on a certain 
morbid condition of the general system. It seems reasonable 
to expect that, when the local affection has once begun to exist, 
local remedies may be of service in checking its progress; but 
that, with a view to the ultimate result, such remedies, as ope- 
rate on the constitution of the patient, may be of as much, if 
not of more, importance, than any local treatment. 

I cannot say, that the abstraction of blood from the neigh- 
bourhood of the diseased joint is never useful; but it certainly 
is not necessary in ordinary cases. The state of the cancellous 
structure of the bones approaches to that of inflammation, and 
the cartilages have the appearance of being inflamed, before 
they begin to ulcerate; but the inflammation is of a specific 
kind, and, like scrofulous inflammation in other parts, is not 



132 ON A SCROFULOUS DISEASE 

likely to be relieved by the loss of blood in the same degree as 
common inflammation. 

Leeches and cold evaporating lotions may, however, be em- 
ployed with advantage for the purpose of arresting an accidental 
attack of inflammation induced by too great exercise of the 
joint, or in any other way. 

It rarely happens that any benefit is to be obtained from the 
application of blisters or liniments; and, indeed, this observa- 
tion may be extended to the whole of that class of remedies, 
which are known by the name of counter-irritants. I much 
doubt whether setons and issues are ever useful, except in some 
cases in which the disease has its seat in the hip-joint, and in 
which the patient suffers, in an unusual degree, from pain and 
muscular spasms in the limb, apparently in consequence of the 
irritation communicated to the trunk of the anterior crural 
nerve. 

There is, however, one rule respecting local treatment, which 
is applicable to all cases, and which can never, with safety, be 
disregarded. The diseased joint should be kept in a state of 
the most perfecUquietude. All motion and pressure of the ar- 
ticulating surfaces against each other is likely to promote the 
ulceration of the cartilages, and hasten the formation of abscess. 
We cannot suppose that rest will contribute to the restoration 
of the bones affected with scrofula to a healthy condition; but 
it may do much towards preventing the disease extending to 
the other textures. With respect to the best mode of obtaining 
this important object, it seems scarcely necessary for me to offer 
any observations in this place, the subject having been already 
fully discussed formerly. I may, however, briefly remark, 
that the application of leathern splints is attended with the very 
best results, except where the disease is situated in the hip. I 
know of no kind of splints which are well adapted to these last- 
mentioned cases; arid the best substitute for them is stripes of 
linen, or leather, spread with a moderately adhesive plaster, laid 
over the joint, and retained by a long roller extending round 
the thigh and pelvis: the patient being at the same time placed 
on one of Mr. Earle's bedsteads, or otherwise on a common 
sofa, with the thigh supported by pillows. 

During the formation of abscesses, fomentations and poultices 
may be employed, with a view to hasten their progress, and re- 



OF THE JOINTS. 133 

Jieve pain: and they may be continued for some time after the 
abscess has burst; or simple dressings may be applied, accord- 
ing to circumstances. 

When, after several abscesses have taken place, -the disposi- 
tion to suppuration appears at length to have ceased, and the 
swollen joint has become diminished in size, it may be expected 
that a curative process, by means of anchylosis, is about to com- 
mence. At this period, pressure by means of stripes of linen, 
spread with soap cerate, or some other moderately adhesive 
plaster, and applied in a circular manner round the limb, will 
be productive of benefit. This will promote the healing of the 
sinuses; and, by more completely preventing the motion of the 
joint, will lessen the chance of fresh suppuration, and favour 
the union of the ulcerated bony surfaces. 

If a portion of the bone has lost its living principle, and has 
exfoliated into the cavity of the joint, the chance of ultimate 
recovery is very much diminished. For the most part, the 
dead bone is so entangled in the living parts, that it is incapable 
of separation by a natural process; and every attempt to remove 
it by artificial means does but occasion a fresh attack of inflam- 
mation and abscess. It is to be observed, however, that bone 
which is found exposed at the bottom of a sinus is not neces- 
sarily doomed to exfoliate. It may be simply ulcerated, and 
may possibly granulate and recover; and the surgeon, there- 
fore, is not warranted in giving a prognosis which is decidedly 
unfavourable, merely because he discovers a piece of exposed 
bone, when he makes an examination with a probe. 

With respect to the constitutional treatment: — It is to be 
supposed that the air of a crowded city must be more or less 
unfavourable; and that a residence on the sea-coast is likely 
to be more beneficial than a residence in the country elsewhere. 
The patient should live on a plain but nutritious diet; and I 
know nothing of more importance than this, — that he should 
be as much as possible out of doors, exposed to the fresh air, in 
warm and temperate weather. 

It is more difficult to appreciate the value of medicines in a 
disease which is so completely chronic, than in acute diseases; 
but, of those, which I have tried, it has appeared to me that 
preparations of steel are much more useful than any others. 
They must, however, be continued, with occasional intermix 

13* 



134 ON A SCROFULOUS DISEASE 

sions, for a great length of time: for two or three years,, or even 
for a longer period. Of course, the operation of them must be 
carefully watched: purgatives should be occasionally exhibited; 
and the use of the steel should be suspended wherever a furred 
tongue or a hot skin indicates that the system is not in a fit 
state to receive it.* Other tonics are useful also, especially 
light bitters combined with the liquor potas&ce; or the latter may 
be given separately in small beer, or in the infusion of cloves. 
The mineral acids may be exhibited when there is a disposition 
to night-sweats, or loss of appetite. I have no doubt that 
iodine, or the hydriodate of potash, may be given with advan- 
tage in these cases, but I cannot say that I have found either 
the one or the other to be productive of those remarkable and 
most beneficial results which are obtained from the use of these 
remedies in some of the other diseases, to which the bones are 
liable. At all events, the iodine cannot be taken constantly, 
and it may very properly be made to alternate with the courses 
of steel medicine; or, in some instances, the iodine and steel 
may be given with much advantage at the same time. In all 
cases, great attention should be paid to the state of the digestive 
organs; the patient's diet should be as plain and as nourishing 
as possible; and where the excretions appear to be unhealthy, 
it will be right to have recourse occasionally to mercurial alter- 
atives. Mercury exhibited in larger doses is invariably pre- 
judicial. 

When the organization of the joint is completely destroyed, 
and the constitution has become affected, so that the patient's 

* According to my experience, steel medicines are not in general adminis- 
tered in such a manner as to do all, which they are really capable of doing, 
towards improving that peculiar state of the constitution in children, which 
is usually distinguished by the appellation of scrofulous. The plan which 1 
have been in the habit of pursuing for many years, and which I have found 
to be followed by the best results, is the following: — I give some simple pre- 
paration, the Vinum ferri (of the old Pharmacopoeia,) for example, not in 
large doses, for a month; then I omit the use of it for a week or ten days; 
then give it for a month again, and so on for two or three, or even for four or 
five years. If it accelerates the pulse, or induces heat of skin, or a furred 
tongue, [ do not hastily lay the medicine aside, but give it in smaller doses, 
and combine it with purgatives, until I find that it no way disagrees with the 
patient. The changes which take place under this system are very gradual, 
but they are not on that account the less distinct; and I have known in- 
stances in which the effect has been to render a child, which was the weakest 
and most delicate, the healthiest and strongest, member of a large family. 



OF THE JOINTS. 135 

health is evidently failing, there can be no doubt of the neces- 
sity of the local disease being removed by amputation: but a 
question concerning the expediency of this operation will often 
arise under other circumstances. The patient has hitherto not 
suffered with respect to his general health, or has suffered in a 
very slight degree: the condition of the diseased joint is such 
that ultimate recovery is very doubtful, and it is certain that 
no better cure is to be expected than that by means of anchy- 
losis, and even this cannot be looked for except after the lapse 
of a considerable time. Is the chance of the ultimate preserva- 
tion of an imperfect limb sufficient to repay the patient for all 
the trouble, and pain, and anxiety, which he must undergo, in 
order that this object should be attained? Undoubtedly it is 
not, particularly with persons belonging to the lower classes of 
society, who have to support themselves by their bodily labour. 
There are, however, some other points to be taken into con- 
sideration; and altogether it is not so easy to determine respect- 
ing the propriety of an operation as, on the first view of the 
subject, it may appear to be. 

A girl was admitted into St. George's Hospital who laboured 
under this disease in the bones and joints of the tarsus. Her 
foot w r as amputated by Mr. Griffiths. In about three weeks 
the stump was perfectly healed ; but now she was seized with 
symptoms which indicated an affection of the mesenteric glands, 
which had not shown itself previously, and she died. , On dis- 
section, numerous glands of the mesentery were found en- 
larged, and containing* a cheesy matter. Another girl, whose 
arm I amputated on account of a scrofulous disease of the elbow, 
became affected in the same manner immediately after the stump 
was healed. She also died, and similar appearances presented 
themselves on dissection. A man, whose leg was amputated 
on account of a scrofulous disease of the tarsus, in a short time 
after the operation began to experience symptoms which indi- 
cated the incipient state of some pulmonic complaint: and soon 
afterwards the other foot became affected in the same manner 
as the first. These are a few of many cases which might be 
adduced, as leading to this conclusion, — that the occurrence of 
this scrofulous disease, in a particular joint, may be the means 
of preventing the scrofulous disposition from showing itself in 
some other organ; and that if the affected joint be removed by 



136 ON A SCROFULOUS DISEASE 

an operation, there is more danger of disease breaking out else- 
where, than there would have been if the operation had not 
been resorted to. 

But we may refer to another order of facts, as showing that 
there are occasions in which the amputation of a scrofulous joint, 
instead of rendering other organs more liable to the same disease, 
may actually produce the opposite effect of preserving them 
from it. It is to be observed, that such a disease of a joint is 
never more than the remote cause of death, and that, where the 
result is fatal, it invariably happens in the following manner. 
The patient is exhausted by a hectic fever, and, in this state of 
debility, disease takes place in the mesentery or lungs, or not 
unfrequently in both these parts at the same time, and it is 
this visceral affeetion which immediately precedes dissolution. 
It is evident, then, that in many cases there is a period of time 
at which the amputation of the limb may be the means of pre- 
venting the establishment of a secondary disease. Nor is this 
all. Visceral disease, which was previously in a state of inac- 
tivity, may assume a new form, and begin to make a rapid pro- 
gress, under the influence of the disease of the joint; and am- 
putation, under these circumstances, may be the means of pre- 
serving the patient, if not altogether, at least for a considerable 
time, perhaps for several years. A young woman was admitted 
into the hospital labouring under scrofulous affection of the 
ankle. It was of long standing, and there were several ab- 
scesses communicating with extensive surfaces of carious bone. 
It was evident that there was no chance^of cure for the disease 
in the. joint. Nevertheless I did not think it right to propose 
to the patient that she should submit to the loss of the limb, as 
she had a troublesome cough, with a purulent expectoration, 
and other marks of pulmonary disease. She, however, ear- 
nestly implored that the ankle might be removed, and at her 
request, and certainly against my own judgment, I performed 
the operation. The stump healed readily. The pulmonary 
symptoms almost immediately subsided; and when I last heard 
of her, four or five years after the operation, she continued 
alive and well.* 

It is evident, from these statements, that the question con- 

* In the last edition of this work I gave another account of the termination 
of this case, which I have since found to be erroneous. 



OF THE JOINTS. 137 

cerning amputation is, in many instances, one of a complicated 
nature, requiring the exercise of no small degree of judgment 
and discrimination on the part of the surgeon, and not to be 
determined, except after a minute investigation of the whole 
case, with respect to the disease in the joint itself, and also 
in whatever relates to the state of the general health at the 
time, and that of the constitution previously. 



In cases, which have a more favourable termination, the joint 
is left in various conditions, accordingly as the disease had 
been more or less advanced at the period when its progress was 
arrested. If it has received a very early attention, the func- 
tions of the joint may be wholly unimpaired; the ulcerated sur- 
faces being cicatrised without the formation of adhesions. Un- 
der these circumstances the place of the cartilage, which has 
been absorbed, is supplied by a membranous substance, and I 
am not justified in asserting that this may not be capable of as- 
suming ultimately the true cartilaginous structure. 

In other instances, adhesions are formed between the articu- 
lating surfaces; and as these are of greater or less extent, so are 
the functions of the joint more or less impaired. Whatever 
may be the degree of mobility, wfrich it retains, it is generally 
to be regarded as so much advantage to the patient, but not al- 
ways. For example: in the joint of the knee it is not uncom- 
mon to find the patella completely united to the condyles of 
the femur, while the head of the tibia admits of a considerable 
degree of flexion and extension. This partial degree of mo- 
bility is productive of no small degree of inconvenience, and 
the patient would, in fact, be in a much better state if the an- 
chylosis were complete in every part, as, in consequence of 
the fixed state of the patella, he has no power to act on the leg 
by means of the extensor muscles. The joint is indeed move- 
able, but its motions are not under the control of the will. 

When recovery takes place after the formation of an abscess 
communicating with the joint, the bones are every where 
united by adhesions, and there is complete anchylosis. Bony 
anchylosis, however, is rare in this disease, and at any rate is 
not established until after the lapse of many years. It is never 
prudent to have recourse to any mechanical means for the pur- 
pose of preventing anchylosis taking place, lest a fresh attack of 



138 ON A SCROFULOUS DISEASE 

inflammation and abscess should be the consequence. We 
may, however, venture, when the circumstances of the case re- 
quire it, to adopt measures for the purpose of gradually placing 
the limb in a more commodious position. For example: when 
the knee has been affected, if left to itself, it often happens that 
the leg becomes fixed at a right, or even an acute angle with 
the thigh; and a light apparatus may be applied to the limb, 
with a screw to the posterior part, by the agency of which the 
leg may be very slowly and cautiously extended. In like man- 
ner, if the elbow be in danger of being anchylosed in the straight 
position, it may be very gradually brought into a state of 
flexion. It is scarcely necessary to explain wherefore, in the 
knee joint, the straight position is to be preferred to the bent; 
while in the elbow it is desirable* to obtain the latter position 
instead of the former. 



SECTION IV. 

CASES OF THIS DISEASE. 

SevefiAL of the cases related in the first section will serve 
to explain the principal circumstances of this scrofulous affec- 
tion of the joints in its most aggravated form. 

The following exhibit it in its less advanced stages, where 
it is still capable of a cure. It may be presumed that in these 
cases, the original disease was that morbid condition of the 
cancellous structure of the bones, which has been just described, 
since the symptoms exactly corresponded to those, which have 
occurred in other cases, and which have been proved by dis- 
section to be of this nature. 

CASE LVII. 

William Moulds, six years of age, having a scrofulous as- 
pect, was admitted into St. George's Hospital, on the 23d of 
February, 1814. 

His left knee was an inch and a half in circumference larger 
than the other. The swelling was puffy and elastic; without 
fluctuation: having nearly the form of the articulating extre- 
mities of the bones; but filling up the space on each side of the 
ligament of the patella. The joint admitted of considerable 



OP THE JOINTS. 159 

motion, but not of complete flexion and extension. He com- 
plained of pain, which was worse at night; but never very se- 
vere. It was somewhat aggravated by pressure. 

His parents attributed the complaint to some trifling hurt, 
whicfyhe had met with a year ago; soon after which, a slight 
degree of pain and tumefaction was first observed, which had 
continued ever since, and had increased, particularly within the 
last month. 

On his admission, with a view to the relief of the external in- 
flammation, blood was taken from the knee by means of leeches 
and cupping. A cold lotion was applied ; and he was directed 
to take gi. of the vinum ferri, with a few drops of the tinctura 
ferri murialis, three times in the day. On the 3d of March, 
the knee was bound up in stripes of linen spread with soap ce- 
rate, chiefly with a view to restrain the motion of the diseased 
joint, without interfering with the patient's taking exercise. 

March 20. The swelling was somewhat diminished; and he 
did not complain of pain. 

April 1. He was in all respects better. As the former pre- 
parations of iron had begun to disagree with him, they were 
changed for ten grains of the carbonate, given three times in 
the day. 

x\pril 20. Scarcely any swelling of the joint remained; and 
there was no pain or stiffness. He quitted the hospital. 

CASE LVIII. 

A. B., a handsome boy, having blue eyes, and light hair, in 
the year 1806 had a scrofulous enlargement of some of the 
glands of his neck, which s.uppurated and burst. 

In the month of June, 1810, being then eight years of age, 
he was observed to limp in walking; but he did not complain 
of pain, and little notice was taken of this circumstance. 

In the beginning of December, 1810, some degree of tume- 
faction was observed of the left instep and ankle. About the 
end of this month he received a trifling hurt of these parts; and 
now the pain of the ankle, which before had been so slight that 
he scarcely spoke of it, became more considerable, and he was 
unable to walk. A gentleman who was consulted, directed 
the application of blisters, but they were productive of no re- 
lief. 



140 ON A SCROFULOUS DISEASE 

In the middle of January, 1811, when I was first consulted^ 
there was a puffy elastic swelling on each side of the ankle and 
instep; there was scarcely any pain when the joint was per* 
fectly quiet; but on attempting to use it, the pain was more 
considerable, and it was particularly aggravated when the heel 
was pressed upwards against the bones of the leg. In other 
respects he was in perfect health. 

I directed him to take the sulphate of iron internally, and to 
avoid all exercise of the joint, walking only on crutches, and 
so as never to place the foot in contact with the ground. Stripes 
of linen spread with soap cerate were applied, for the purpose 
of more effectually restraining motion. 

I did not see him again until the beginning of March, when 
the pain and swelling were found to be somewhat diminished. 
As the stripes of soap cerate did not seem sufficiently to answer 
the intended purpose, a light pasteboard splint was applied on 
each side of the leg and foot, and secured by means of a ban- 
dage. 

April 12th. The puffy swelling was evidently diminished, 
and there was no pain, even when the heel was pressed upwards 
against the tibia. The same treatment was continued. 

May 26th. The swelling was farther diminished; and, on 
the 29th of June, the affected foot and ankle scarcely differed 
in appearance from the other. He was free from pain even 
on motion. The splints were left off, but it was directed that 
he should continue to wear the bandage. He was allowed oc- 
casionally to put his foot on the ground. 

July 20th. He continued well. He went to the sea-side, 
with directions to continue the steel medicine, and to bathe in 
the sea twice in the week. 

CASE L1X. 

George Lavel, nine years of age, and having a scrofulous ap- 
pearance, in January, 1817, complained of an aching in his left 
elbow, and in about two or three months it was observed that 
the elbow was swollen. In May, 1817, he became an out-pa- 
tient of St. George's Hospital. At this time the elbow was 
swollen and painful; but the pain arose chiefly from an abscess 
which presented itself underneath the skin on the inside. Af- 
ter the abscess had burst, it was observed that the swelling, so 



OF THE JOINTS. 14i 

far as it was independent of it, was not considerable, and that 
seemed to arise entirely from an effusion of serum, and coagu- 
lated lymph into the cellular membrane external to the joint. 
From this time he suffered very little pain, until the beginning 
of January, ISIS, when another abscess began to show itself on 
the outside of the elbow. On the 28th of January he was re- 
ceived as an in-patient of the hospital. The joint now admitted 
of very limited motion. Whenever it was moved, or when the 
articulating surfaces were pressed against each other, he com- 
plained of some, but not of severe pain. He kept the fore-arm 
in the half-bent position, and walked about, supporting the hand 
in a sling, with very little inconvenience. 

In the beginning of February, he was directed to take six 
grains of carbonate of iron three times in the day; and a purge 
of calomel and rhubarb was administered occasionally. The 
abscess was opened, and a poultice was applied. 

March 1st. The joint was smaller, but he was feverish, and 
suffered pain at night. 

March 21st. The swelling was much diminished, the pain 
had abated; he slept well at night, and was free from fever. 

In the middle of May there was a recurrence of pain in the 
joint, and another abscess presented itself on the outside, which 
was opened on the 19th of May. After this a fourth abscess 
formed on the fore-part of the elbow, and broke on the 23d of 
June. 

July 4th. There was little or no swelling. He was free 
from pain; the abscesses continued open, discharging a very 
small quantity of matter. 

The poultices and fomentations, which had been hitherto 
employed during the formation of the abscesses, were now left 
off, and some simple dressings, and a bandage, were applied in 
their stead. The swelling continued to subside; he had no 
return of pain or abscess. On the 4th of September, the joint 
was not larger than the other; it admitted of much more motion 
than formerly; there was no pain; there was still one sinus, 
which was not completely closed, and which discharged a mi- 
nute and almost imperceptible quantity of matter: all the other 
abscesses were completely healed. 
13 



142 ON A SCROFULOUS DISEASE 

The three preceding cases will serve to illustrate the history 
of this disease; but that which follows affords a better example 
of the treatment, which I have of late years been led to adopt 
for its relief, and which, according to my experience, is, on the 
whole, much more successful than any other. 

CASE LX. 

Master H. K., being at that time two years of age, was brought 
from the country for my opinion, concerning a disease in his 
knee, in the latter part of December, 1831. 

The right knee was enlarged. The leg was half bent on the 
thigh, and the joint admitted of motion to only a limited extent. 
The swelling manifestly arose, not from fluid in the cavity of 
the synovial membrane, but from an effusion of lymph and se- 
rum in the cellular membrane external to it. The projecting 
condyles of the femur presented the usual rounded appearance 
which is observable in cases of the scrofulous disease of this 
articulation. The child complained very little, or not at all, of 
pain. There were no marks of derangement of the general 
health. 

The enlargement and stiffness of the knee had been first ob- 
served about the end of the preceding October, and had gra- 
dually increased up to the time of my being consulted. A 
pasteboard splint was applied on each side of the joint; the 
vinum ferri was prescribed to be taken twice daily for three 
weeks or a month, then omitted for a week or ten days, and 
then to be given for a month again, and so on. It was also 
directed that some calomel should be administered about once 
in three weeks, with an occasional dose of rhubarb and sal 
polychrest in the intervals; that he should be taken back into 
the country; that he. should be drawn out of doors in an open 
carriage, so as to be exposed to the fresh air for some hours, 
daily, in fine weather; and lastly, that he should be prevented, 
as much as possible, from using the limb. 

May, 1832. I saw the patient again in London. The disease 
had made no manifest progress. I recommended that he should 
go again into the country, and pursue the same plan of treat- 
ment in all respects. 

Soon afterwards a swelling was observed, for the first time, 
on the inside of the thigh immediately above the knee. 



OF THE JOINTS. 143 

September, 1832. The joint itself appeared diminished in 
size, but the swelling on the inside of the thigh had increased. 
It manifestly contained fluid, and had all the appearance of an 
abscess. No alteration was made in the treatment. 

In May, 1833, when he was brought to London, for the 
fourth time, the collection of fluid in the inside of the thigh 
was much reduced. The swelling of the knee was diminished 
also. The same remedies were directed as before. 

In June, 1S33, the swelling on the inside of the thigh had 
altogether disappeared. The diseased knee was scarcely larger 
than the other; but it was stiff, and the leg was bent at a right 
angle with the thigh. 

It was now directed that the splints should be left off, and 
that an instrument should be applied at the back part of the 
limb, attached to the thigh and leg, so as to give much sup- 
port to the joint, at the same time that it was furnished with a 
screw, by means of which the leg might be very cautiously and 
gradually extended. No change was made in the treatment in 
other respects. 

The machine completely answered the purpose for which it 
was intended. In a fortnight after it was first applied, the 
little boy was able to walk across the room without difficulty, 
and altogether it was so convenient, that he was allowed to 
wear it during the night, by his own express desire. 

In August, 1833, the leg was much straighter, and, in other 
respects, the joint was^ in a better state than at any former period. 

January 20, 1834. The knee was reduced to nearly its natu- 
ral size. There were no perceptible remains of the swelling 
which had been supposed to be an abscess. The leg was bent 
only in a very slight degree, and the patella moved readily 
over the condyles of the femur. The little boy's health was 
good; he was free from pain, and he could walk tolerably well 
with the aid of the instrument. It was advised that he should 
return into the country, and continue on precisely the same 
plan of treatment as heretofore, except being allowed to exer- 
cise the limb more freely. 



The following case is interesting in a pathological point of 
view, illustrating, as it does, the morbid changes which the 
disease produces in the various stages of its progress. It is 3 



144 ON A SCROFULOUS DISEASE 

however, introduced in this place, as it shows to what extent 
the symptoms may be modified and aggravated by an acciden- 
tal, and apparently, trivial circumstance. 

CASE LXI. 

Captain D., in mounting his horse, some time in the year 
1820, experienced an acute pain in the right hip, which was 
not, however, of long duration. He afterwards felt, occasion- 
ally, similar sensations, which were induced by walking, but 
they were not severe, and therefore attracted very little of his 
attention. 

In December, 1822, he was attacked with pain in the same 
hip, which did not subside as formerly. It occasioned lame- 
ness, so that he could not proceed many yards without stopping 
to rest. This pain increased; and, in February, 1823, he suf- 
fered so much that he was wholly incapable of going from home, 
except in a carriage. He now consulted an eminent surgeon, 
who recommended the application of leeches, blisters, &c. One 
evening, after the application of leeches, he had a paroxysm of 
violent pain, attended with spasmodic action of the muscles of 
the thigh. The pain, during this attack, was so excruciating, 
that, to use his own expression, he wished for immediate death. 
He took not less than 150 drops of laudanum before he ob- 
tained relief. From this time, however, he was never wholly 
free from pain; and he was also liable to repeated attacks of 
more intense suffering, attended with violent spasms of the 
muscles of the thigh. /The slightest motion of the limb in- 
duced one of these attacks of spasm, during which the thigh 
was jerked in a most remarkable manner. He w r as in this 
state when I was first consulted, in the summer of 1823. In 
September, 1823, the spasmodic affection gradually subsided; 
and in the course of the October following a tumour presented 
itself on the anterior part of the thigh, in the situation of the 
femoral blood-vessels. The tumour appeared to contain fluid, 
and in one part of it a pulsation was perceptible, which might 
have led a superficial observer to mistake it for an aneurism. 
About the same time, he became affected with a cough, lost 
his appetite, was languid, and exhausted by the slightest exer- 
tion. Soon afterwards he expectorated pus; and he died with 
symptoms of phthisis pulmonalis, on the 11th of December. 



OF THE JOINTS. 145 

On examining the body after death the lungs were found ex- 
tensively diseased, containing tubercles, many of which w 7 ere in 
a state of suppuration. The cartilages of the right hip were de- 
stroyed by ulceration, and the bones of the joint were in a state 
of caries. On making a section of the head of the femur, it was 
found to contain a less quantity of earthy matter than exists in 
a healthy bone, with a deposite of yellow substance in its can- 
cellous structure. The synovial membrane and capsular liga- 
ment were considerably thickened, and a mass of coagulated 
lymph had been deposited round the neck of the femur. There 
was a collection of thin pus among the muscles on the anterior 
part of the thigh, below the hip-joint, but communicating with 
it. The tumour thus formed was of the size of a large orange, 
and, being situated under the femoral artery, the latter was 
thereby raised out of its natural situation. There were two en- 
larged lymphatic glands, each of the size of a walnut, imme- 
diately below the crural arch, on the fore part of the joint, and 
these lay in contact with, and immediately behind, two branches 
of the lumbar nerves, so as to keep the latter on the stretch, 
like the strings passing over the bridge of a violin. This last- 
mentioned circumstance seemed to afford a reasonable explana- 
tion of the spasmodic affection to which the patient had been 
liable; and which, probably, had become relieved in conse- 
quence of some degree of diminution in the size of the glands 
after the escape of the abscess from the joint. 

No disease had been supposed to exist in the left hip-joint 
previous to the patient's death. But, on examining it after- 
wards, the head of the femur was found to be softer than na- 
tural, so that it could be divided with a scalpel. In some parts 
the vascularity of the bone was preternaturally increased. In 
other parts the vascularity seemed to be less than natural, and 
a yellow cheesy substance had been deposited in its cancelli. 
The synovial membrane and ligaments of the left hip were in a 
natural state. 



In concluding this chapter, I have one farther observation to 
offer, which may be of some importance to those who are en- 
gaged in studying the pathology and investigating the morbid 
anatomy of the joints. In the disease of which 1 have just 

13* 



146 ON A SCROFULOUS DISEASE OF THE JOINTS. 

treated, the bones are rendered preternaturally soft, so that 
they may be cut with a scalpel without turning its edge, or 
even crushed between the fingers. But this softened state of 
the bones is only one of the morbid changes which scrofula in- 
duces in these textures; and we are not hastily to conclude, 
where we meet with the bones thus deprived of their earthy 
matter, that this is always the original malady. In a patient 
who met with a compound fracture of the leg close to the ankle, 
and who died some time after the accident, I found, on dissec- 
tion, the fractured surfaces in a state of caries, and the neigh- 
bouring portions of the tibia and fibula as soft as they would 
have been in the most scrofulous subject. I have seen a num- 
ber of other cases, which prove that a preternatural softness 
may occur as a consequence of inflammation and caries affecting 
a bone, which was previously in a healthy state. In cases of 
primary ulceration of the cartilage, the morbid appearances are 
at first confined to the cartilage and bony surface, to which it is 
connected. When the disease is farther advanced; when the 
bones are extensively ulcerated, and inflammation has taken 
place in their substance; the earthy matter becomes absorbed, 
and the bones lose their natural hardness, so that they may be 
divided with little force. If we find the bones deprived of a 
large portion of their earthy matter, and this change connected 
with extensive destruction by caries, but without that effusion 
of serous fluid, and yellow cheesy substance into the cancelli, 
which has been formerly described, we may well doubt whether 
this morbid change be not the consequence, rather than the 
cause, of the caries with which it is combined. At any rate, it 
is to the examination of cases in which the disease is in its early 
stage, and not of those in which it has made great ravages, that 
we are to look chiefly for pathological information as to the na- 
ture of the morbid action which has taken place, and the par- 
ticular texture in which it has had its origin. 



CHAPTER VI. 

ON CARIES OF THE SPINE. 



SECTION I. 



PATHOLOGICAL OBSERVATIONS. 



It is obvious, from the structure of the joints between the 
bodies of the vertebrae, that they can be liable to no diseases 
bearing any resemblance to the affections of the synovial mem- 
brane, which occur in other articulations. But analogy would 
lead us to expect, what experience demonstrates, that those dis- 
eases, which commence in the harder textures, may occur here 
as elsewhere, and that an extensive caries of the spine may have 
its origin, sometimes in an ulceration of the intervertebral car- 
tilages, and at other times in a morbid condition of the can- 
cellous structure of the bodies of the vertebrae. 

In one of the cases which have been related in a former 
chapter, where ulceration of the articular cartilages had begun 
in several other parts, those between the bodies of some of the 
dorsal vertebrae were found to have been very much altered 
from their natural structure. I had an opportunity of noticing 
a similar morbid condition of two of the intervertebral cartilages 
in a patient, who, some time after having received a blow on the 
loins, was affected with such symptoms as induced Mr. Keate 
to consider his case as one of incipient caries of the spine, and, 
to treat it accordingly, with caustic issues; and who, under these 
circumstances, died of another complaint. 

Opportunities of examining the morbid appearances in this 
very early stage of disease in the spine are of very rare occur- 
rence, but they are sufficiently frequent where the disease has 
made greater progress; and in such cases I have, in some, in- 
stances, found the intervertebral cartilages in a state of ulcera- 
tion, while the bones were either in a perfectly healthy state, 
or merely affected with chronic inflammation, without having 



148 ON CARIES OF THE SPINE. 

lost their natural texture and hardness; while in others it has 
been manifest that the original disease has been that peculiar 
scrofulous condition of the bones, the effects of which in the 
bones and joints of the extremities have been described at length 
in the preceding chapter. 

The following cases illustrate the foregoing observations, and 
(if I am not mistaken) will be found to explain the whole of 
the pathological history of caries of the spine, with the excep- 
tion of those circumstances which I shall have occasion to no- 
tice when describing the symptoms, which the disease exhibits 
in the living person. 

CASE LXII. 

Christiana Clear, a girl eight years of age, was admitted into 
the Infirmary of the parish of St. George, Hanover Square, in 
the year 1808, on account of a disease of the spine. At this 
time, the upper part of the spine was bent forward, and the 
spinous processes of some of the dorsal vertebrae formed a pre- 
ternatural projection at the posterior part; but still she was able 
to walk without assistance. 

Soon after her admission an abscess presented itself, and burst 
in the groin; and this was followed by a second abscess, which 
burst near the former. 

The child was now under the necessity of being confined en- 
tirely to her bed. The abscesses continued to discharge pus. 
She became affected with hectic fever; nevertheless, more than 
two years elapsed from the time of her having been first ad- 
mitted into the infirmary before she died. 

The body was examined by Mr. Howship, to whom I am 
indebted for this account of the case. It was universally ana- 
sarcous. The abdominal muscles were so wasted, that scarcely 
any vestige of them was perceptible. This probably arose from 
the circumstances of the child having remained in bed for so 
long a time previous to her death, and having scarcely ever 
varied her position. 

At the posterior part of the abdomen, there was a confused 
mass of soft substance, which proved to be the parietes of an 
abscess communicating with the orifices in the groin. 

The bodies of the lowest dorsal and three superior lumbar 
vertebrae were found at the posterior part of the abscess, nearly 



ON CARIES OF THE SPINE. 149 

consumed by caries. There were no remains of the interver- 
tebral cartilages between the tenth and eleventh dorsal, nor of 
those between the third and fourth lumbar vertebrae. These 
intervertebral spaces were filled with pus; and the opposite 
surfaces of the vertebrae were carious, but only to a small ex- 
tent. The central part of the intervertebral cartilage between 
the ninth and tenth dorsal vertebrae had been completely ab- 
sorbed, and pus was found in its place. Externally to this, the 
concentric layers of elastic cartilage were entire, though some- 
what altered from their natural appearance. 

CASE LXIII. 

Mr. M., a young man, in the summer of 1816, became af- 
fected with pain in his back, and general debility, w T hich he at- 
tributed to his having lain on damp ground, while in the Island 
of Ascension, in the preceding March. In the beginning of 
September he sailed for England, being compelled to return 
home, on account of the state of his health. 

In February, 1817, he arrived in London; complaining of 
pain in the back, and numbness of the thighs. Soon after- 
wards, on examining the spine, it was observed that that part 
of it, which is formed by the dorsal vertebrae, was incurvated 
forward, and that there was an evident lateral incurvation also. 
After this, an abscess burst in one groin, and continued open, 
discharging a large quantity of matter. The lower extremities 
became imperfectly paralyzed; he lay constantly on one side, 
with the thighs drawn forward, so that his knees nearly touched 
his chin, and never varied from this position. He lingered un- 
til the 10th of August, 1818, when he died. 

On inspecting the body, I found an abscess, which occupied 
nearly the whole of the anterior surface of the spine, from 
the upper part of the. posterior mediastinum as low as the 
pelvis, and which communicated w T ith each groin, extending 
downwards in the direction of the psose muscles. In many 
parts, in consequence of the contact of the matter of the abscess, 
the bodies of the vertebrae, and even the heads of the ribs, were 
affected with a superficial caries. 

There were no remains of the intervertebral cartilage be- 
tween the fourth and fifth dorsal vertebrae, and the opposite 
surfaces of these two vertebrae w r ere consumed by caries to 



150 ON CARIES OF THE SPINE. 

some extent, and hence arose the curvature of the spine for- 
ward; and they were consumed to a greater extent towards the 
left side than towards the right, and hence arose the lateral cur- 
vature. 

The intervertebral cartilages between the eleventh and twelfth 
dorsal vertebrae had also entirely disappeared, and the opposite 
surfaces of these bones were in a state of caries; but this had 
not extended itself sufficiently to occasion any sensible loss of 
bony substance. 

The intervertebral cartilages between the third and fourth, 
fifth and sixth, seventh and eighth, tenth and eleventh dorsal 
vertebrae, and also that between the twelfth dorsal and first 
lumbar vertebrae, were all found in a perfectly natural state to- 
wards the circumference; but in the centre they were of a dark 
colour; and on the surfaces towards the bones they, as well as 
the bones themselves, were in a state of incipient ulceration, 
but without any appearance of pus having been secreted. 

All the other intervertebral cartilages were, throughout their 
whole substance, in a natural condition; and the bones of the 
vertebrae every where had their natural texture and hardiness. 
On laying open the theca vertebralis, the membranes of the 
spinal marrow were found adhering together, behind the space 
between the fourth and fifth dorsal vertebrae. 

CASE LXIV. 

Mary Price, sixteen years of age, was admitted into St. 
George's Hospital, on the 24th of December, 1828. 

She complained of pain in the loins, which was aggravated 
by pressure made in the situation of the upper lumbar vertebrae, 
and by sitting erect. 

She also complained of pain in the left hip, which was more 
severe during the night than in the day, and attended with pain- 
ful startings of the limb. The pain extended from the groin 
downwards, and was aggravated by exercise, and by pressure 
on the great trochanter. 

She was confined to her bed in the horizontal posture; and 
an issue was made with caustic in the left loin. 

Under this treatment, the symptoms were almost entirely 
relieved. But she now began to complain of a cough, attended 
with pain in the chest, and difficulty in making a full inspira- 



ON CARIES OF THE SPINE. 151 

tion. Soon afterwards she expectorated pus; and she died on 
the 18th of March. 

On dissection, tubercles with a considerable abscess were 
found in the left lung. 

There was a small abscess lying behind the left psoas muscle, 
which communicated with a space between the fourth and fifth 
lumbar vertebrae, formed by the ulceration of the intervertebral 
cartilages and the adjoining surfaces of the vertebrae. The 
bones of the vertebrae retained their natural hardness, but were 
of a pale colour, apparently in consequence of their possessing 
a somewhat smaller degree of vascularity than under ordinary 
circumstances. 

In the left hip-joint the synovial membrane appeared to be 
a little more vascular than usual. In the neighbourhood of the 
insertion of the round ligament the cartilage of the acetabulum 
had disappeared, but it had been replaced by a membranous 
substance, adhering to what would have been otherwise an ex- 
posed surface of bone. In another' spot, at the upper part of 
the acetabulum, the cartilage had also disappeared, and the 
bone itself had become exposed. The bone, however, was hard 
and compact, and rather more elevated than the bone in the 
neighbourhood, so as to justify the notion that it had become 
cicatrised after having been in a state of caries. 

CASE LXV. 

Charlotte James, nineteen years of age, was admitted into 
St. George's Hospital on the 30th of May, 1821. About a 
month before her admission she had experienced pain in the 
loins, which was relieved by cupping. At the time of her ad- 
mission she had violent pain in the left lower limb, from the 
hip to the foot; and soon afterwards she again complained of 
pain in the loins; about the same period a tumour presented it- 
self in the loins, on the right side. Her constitution also be- 
came affected with hectic symptoms. 

On the 2tl of June the tumour was punctured, and sixteen 
ounces of pus were evacuated. Another abscess presented it- 
self io the groin. 

The hectic symptoms continued; she gradually sunk, and 
died on the 3d of August. * 

On dissection the bodies of the three or four inferior lumbar 



152 ON CARIES OF THE SPINE. 

vertebrae were found preternaturally vascular, and of a dark? 
and almost black colour; but they retained their natural texture 
and hardness, and had undergone none of those changes which 
mark the existence of the scrofulous affection of the bones. 
The intervertebral cartilages were in a natural state; but the 
body of one of the vertebrae was superficially ulcerated for 
about the extent of a sixpence on one side, towards the poste- 
rior part. A large abscess communicated with the ulcerated 
surface, and occupied the situation of the psoas muscle of the 
left side, extending downwards to the groin. 

CASE LXVI. 

Edward Griffiths, forty-five years of age, was admitted into 
St George's Hospital, on the 15th of April, 1818, on account 
of an abscess, which presented itself in the left groin. He said 
that about four months before his admission, he had been seized 
with pain in the loins, and that the tumour in the groin had 
appeared about six weeks after the commencement of the pain. 

He was directed to remain constantly in the horizontal posi- 
tion; and in a short time the tumour formed by the abscess in 
the groin disappeared, and another showed itself over the left 
os innominalum. On the 15th of May, this abscess was opened, 
and about forty ounces of pus were discharged. After this, he 
gradually sunk, and died, worn out by profuse suppuration, on 
the 19th of August following. 

On dissection, it was found that the cancellous structure of 
all the dorsal and lumbar vertebrae was of a dark red colour, 
and softer than natural, so that they might be cut with a com- 
mon scalpel, or even crushed by the pressure of the thumb and 
fingers. 

The opposite surfaces of the bodies of the second and third 
lumbar vertebrae, and of the cartilage between them, at the 
posterior part, were extensively destroyed by ulceration. An- 
teriorly, the bones and the intervertebral cartilage were entire, 
and the latter was in a perfectly natural state; but the bones 
throughout were of a- dark and almost black colour. 

On one side of the body of the twelfth dorsal vertebra, there 
was a small ulcerated spot, forming an opening, which extended 
itself into a small cavity into the centre of the bone. This 
bone was also of a black colour; but the intervertebral cartilages 



ON CARIES OF THE SPINE. 153 

belonging to it, as well as the intervertebral cartilages connected 
with the other vertebrae, were in a perfectly natural state. 

The abscess had originated in the carious surfaces of the se- 
cond and third lumbar vertebrae, and had extended itself behind 
the left psoas muscle, as low as the upper and anterior part of 
the left thigh; where it made a turn backwards on the inside of 
the tendon of the psoas muscle, and thus made its way to the 
place where it was opened on the posterior part. 

The ribs were throughout unusually vascular and brittle, so 
that they might be broken by the slightest force. There were 
vomicae in the lungs, and tubercles in the liver. 

CASE LVII. 

Henry Shaw, seventeen years of age, consulted Mr. Earle 
in November, 1816, on account of a complaint which had be- 
gun about three months before, and of which the following 
w T ere the most remarkable symptoms: — 

He had frequent attacks of pain in the head, attended with 
giddiness. Occasionally he had fits, in which he was for a short 
time insensible, with a spasmodic action of some of the muscles 
of the neck. The right eye was amaurotic, and there was con- 
stant tirinitus aurium. His mental faculties were for the most 
part unimpaired. 

By Mr. Earle's directions, he was cupped; purgatives were 
administered, and he was kept under the influence of mercury 
during six weeks, at the end of which time his symptoms had 
nearly disappeared. 

About the end of May, 1817, he w r ent on a visit into the 
country; and while there, he one day tripped and fell in crossing 
the room. Another set of symptoms now showed themselves, 
for-which he was brought to London. At this time he had 
pain in the back and in the right side, shooting in the direction 
of the costal nerves. He was subject to severe cramps in the 
stomach; his bowels were irregular; and he breathed with dif- 
ficulty. He had cramps in his lower limbs, and his locomotive 
powers were impaired, though there was no actual paralysis of 
the muscles. His general health was much deranged. On 
examining the spine, Mr. Earle discovered a curvature, of 
which the convexity was turned backwards, occupying about 
the three middle dorsal vertebrae; and this was attended with a 
14 



154 ON CARIES OF THE SPINE. 

considerable alteration in the form of the chest. He was now 
removed into St. Bartholomew's Hospital, where Mr. Earle 
directed him to remain constantly in the horizontal position, 
and an issue was made with caustic on each side of the spine. 
In a short time he lost the cramps of his lower extremities; but 
his general health continued to fail, and the difficulty of breath- 
ing increased. 

In the middle of December he quitted the hospital. The 
exertion of being moved seemed to aggravate the disease. He 
was seized with numbness of the left leg and thigh; the dysp- 
noea became worse; and he sunk and died in convulsions, on 
the 23d of December, 1817. 

On dissection, the arachnoid membrane was found opaque 
and thickened. A large tumour, of almost cartilaginous hard- 
ness, was found in the anterior lobe, and a similar one in the 
posterior lobe, of the right hemisphere of the cerebrum; and a 
third tumour occupied the greater part of the right lobe of the 
cerebellum. The ventricles were distended with water. 

The right lung was studded with tubercles, and adhered uni- 
versally to the pleura costalis. There was a large abscess of 
the posterior mediastinum ; at the bottom of w r hich, the bodies 
of two of the vertebrae, together with the intervertebral car- 
tilage between them, were found nearly destroyed by ulcera- 
tion. The other intervertebral cartilages were in a natural 
state; but the bodies of the vertebrae were soft, and many of 
thern were beginning to ulcerate. The ribs were porous, their 
cancelli being filled with a curdly matter; and they w T ere soft, 
so that they might be divided with a scalpel. Four of the ribs 
were separated from their attachment to the spine, and were 
ulcerated as far as their tubercles. 



It is unnecessary for me to adduce other cases of caries of 
the spine in which 1 had the opportunity of examining the 
appearances after death, and which did not essentially differ 
from those already related. The pathological history of the 
disease may be thus briefly recapitulated. 

In some instances it has its origin in that peculiar softened, 
and otherwise altered condition of the bodies of the vertebrae, 
the appearance of which in the bones belonging to other joints, 
has been described, in the last chapter, and which seems to be 



ON CARIES OF THE SPINE. loo 

connected with what is called a scrofulous state of constitution. 
In these cases ulceration may begin on any part of the surface, 
or even in the centre of the bone, but in general the first effects 
of it are perceptible where the intervertebral cartilage is con- 
nected with it, and in the intervertebral cartilage itself. 

In other cases the vertebrae retain their natural texture and 
hardness, and the first indication of the disease is ulceration cf 
one or more of the intervertebral cartilages, and of the surfaces 
of bone with which they are connected. 

There is still another order of cases, but these are of more 
rare occurrence, in which the bodies of the vertebrae are affected 
with chronic inflammation, of which ulceration of the interver- 
tebral cartilages is the consequence. 

In whichever of these ways the disease begins, if not checked 
in its progress, it proceeds to the destruction of the bodies of 
the vertebrae and intervertebral cartilages, leaving the posterior 
parts of the vertebrae unaffected by it; the necessary conse- 
quence of which is, an incurvation of the spine forward, and a 
projection of the spinous processes posteriorly. 

At this period of the disease the membranes of the spinal 
chord sometimes become affected with a chronic inflammation, 
which may extend even to the spinal chord itself; and where 
there is much incurvation, the latter not only becomes incur- 
vated with it, but actually compressed in such a manner as can- 
not fail to interfere with the due performance of its functions. 

Suppuration sometimes takes place at a very early period: 
at other times, not until the disease has made considerable pro- 
gress. The soft parts in the neighbourhood of the abscess be- 
come thickened and consolidated, forming a thick capsule, in 
which the abscess is sometimes retained for several successive 
years, but from which it ultimately makes its way to the sur- 
face, presenting itself in one or another situation, according to 
circumstances. 

In the advanced stage of the disease, new bone is often de- 
posited in irregular masses on the surface of the bodies of the 
neighbouring vertebrae, and where recovery takes place, the 
carious surface of the vertebra above coming in contact with that 
of the vertebra below, they become united with each other, at 
first, by soft substance, afterwards by bony anchylosis. The 
disposition to anchylosis is not the same under all circum- 



156 ON CARIES OF THE SPINE. 

stances: it is much less where the bones are affected by scrofula 
than where they retain their natural texture and hardness; and 
this explains wherefore, in the former class of cases, a cure is 
effected with more difficulty than in the latter. 

Occasionally, portions of the ulcerated or carious bone lose 
their vitality, and, having become detached, are found lying 
loose in the cavity of the abscess. It is scarcely necessary to 
add, that the existence of such exfoliations is of itself almost 
sufficient to preclude all chance of the patient's recovery. 

The foregoing observations are intended to apply to cases of 
caries of the spine originating in the spine itself; but those who 
are engaged in investigating the morbid anatomy of these dis- 
eases, will find it necessary to distinguish between these and 
other cases, which may at first appear to be of a similar, but 
which are in reality of a different nature. The long-continued 
pressure of an abscess which has originated in the neighbouring 
soft parts; of an aneurism of the aorta; of a mass of enlarged 
lymphatic glands, or of any other tumour; may produce ulce- 
ration of the bodies of the vertebrae: and here we find the in- 
tervertebral cartilages in general to be very little, or not at all 
affected; so that they are left projecting nearly or quite of their 
natural size, while the bones themselves are in a great degree 
consumed. In such cases, where the spine is carious in conse- 
quence of disease beginning external to it, the symptoms are 
not the same as where it has begun in the spine itself. For the 
most part, the affection of the spine is not suspected during the 
patient's life-time; and after death it is easy to trace the origin 
of the disease in the contiguous parts. 

Not unfrequently, however, we find caries from disease of 
the spine itself complicated with caries from external pressure. 
For example, disease of the vertebrae, or intervertebral carti- 
lages, occasions caries, and this is followed by the formation of 
abscess. The matter having become accumulated in considera- 
ble quantity, the abscess occupies a large space; and by its pres- 
sure on the surfaces of the vertebrae in the neighbourhood, 
causes an extensive caries of them far beyond the boundaries 
of the original disease. 



OK CARIES OF THE SPINE. 157 



SECTION II. 



ON THE SYMPTOMS OF CARIES OF THE SPINE. 

As these diseases of the spine correspond in this respect, that 
they terminate in a more or less extensive caries, it may be 
expected that there must be a certain degree of resemblance in 
the symptoms which they produce. This resemblance is, in- 
deed, greater than where the same morbid affections take place 
in other joints. I suspect that, where the disease is of scrofu- 
lous origin, affecting the cancellous structure of the bones, it is 
more immediately followed by suppuration, than where it 
commences in the form of ulceration of the intervertebral carti- 
lages; and that in cases of the latter description the pain and ten- 
derness in the situation of the carious portion of the spine is 
more considerable than in those of the former. But farther 
than this, nothing, which 1 have hitherto observed, enables me 
to point out any circumstances, in which the symptoms of these 
different diseases differ; nor do I believe (however desirable it 
may be to do so,) that it is possible, in the present state of our 
knowledge, to distinguish them from each other, with any de- 
gree of certainty, in the living person. Perhaps future obser- 
vations may throw light on this important subject. In the 
mean time, when I speak of the symptoms of caries of the 
spine, it is to be understood that the observations which I make 
are, as far as I know, applicable to the various cases of this 
description; those only excepted, in which the caries is a se- 
condary affection, the consequence of the pressure of a tumour 
in the neighbourhood. 

Caries of the spine usually occurs in those who are either 
originally of a weak constitution, or whose bodily powers have 
become diminished under the influence of some previous ail- 
ment. Thus we find it following scarlet fever, small-pox, a 
simple continued, or rheumatic fever, or a protracted or ill- 
conducted mercurial course. In some cases, however, it takes 
place under very different circumstances, and individuals are 
attacked by it, who were previously in a state of perfect 
health. 

It is evident that, independently of the effects which, in its 

14* 



158 ON CARIES OF THE SPINE. 

most advanced stage, it produces on the general system, two or- 
ders of symptoms may be the result of this disease. 1st, Those 
which are the immediate consequence of the morbid condition 
of the vertebrae themselves, and of the intervertebral cartilages. 
2dly, Those which arise from pressure on the spinal chord, or 
from irritation, propagated in some way or another to this im- 
portant part of the nervous system, or to the nerves to which 
it gives origin; and these symptoms may be thus briefly enu- 
merated : — 

1st, Pain and tenderness in the situation of the carious ver- 
tebrae. 

2dly. Curvature of the spine forward, with an angular pro- 
jection of the spinous processes posteriorly, the result of the bo- 
dies of the vertebrae having been destroyed, while the other 
parts of these bones remain entire. 

3dly. Abscess commencing imperceptibly, but at last pre- 
senting itself as an external tumour. 

4thly. Pains, loss of sensation, coldness, muscular spasms, 
and paralysis of the extremities. 

5thly. Derangement of the functions of the various viscera, 
which are capable of being influenced by that portion of the 
spinal chord which is implicated in the disease. 

But the whole of these symptoms are not met with in every 
instance; nor do those which actually exist always show them- 
selves in the same order. They are modified and altered ac- 
cording to a variety of circumstances, and to such an extent, 
that a history of them which is applicable to one case, may be 
found to be wholly inapplicable to another. In fact, there is 
scarcely any disease which presents itself under a greater num- 
ber of forms, or in which, in the early stages, at least, so much 
experience and discrimination are necessary to enable us to 
form a right diagnosis. 

In the majority of cases, the first symptom which the patient 
notices, is pain referred to that part of the spine in which the 
caries exists; at first trifling, but becoming more severe after- 
wards. The pain is aggravated by any sudden motion of the 
spine; by percussion, or by a jar communicated to it in any 
other way ; as by stamping on the ground, striking the foot ac- 
cidentally against a stone, sneezing, or coughing. In the ad- 
vanced stage of the disease the pain is sometimes so severe, 



ON CARIES OF THE SPINE, 159 

and so easily induced, that the patient cannot bear the slightest 
movement. Yet, in other cases, there is sometimes no pain in 
the spine whatever, from the first access of the disease to its 
termination. I was consulted concerning a young gentleman, 
in whom, judging from the degree of distortion, I was satis- 
fied that the bodies of not fewer than four or five of the dorsal 
vertebrae must have been wholly destroyed, and that the dis- 
ease had been going on for several years; yet he had never 
been known to complain of pain; and the first circumstance 
which attracted the attention of the parents, was the angular 
projection of the spinous processes. This patient ultimately 
died, and on examining the body after death, a large abscess 
was discovered lying on the surface of the carious vertebrae* 
In another case, in which the disease was supposed to have been 
cured, and the patient had not experienced pain for the two or 
three preceding years, on examining the appearances after death, 
1 found the bodies of the vertebrae still in a state of caries, and 
an abscess, containing not less than half a pint of matter, con- 
nected with them. 

The distortion of the spine, which occurs in these cases, is of 
a peculiar kind. It is bent forward, so as to form an angle 
projecting posteriorly; and it is evident that this cannot hap- 
pen without the destruction of the bodies of one or more of 
the vertebrae. 

It is not less evident that the caries must have made consi- 
derable progress before this symptom shows itself; and accord- 
ingly, we find that it has been preceded by r pain, referred to 
the affected part, during a period which varies from three 
months to two years, and which is sometimes even longer than 
this. I have already mentioned that there are exceptions to this 
general rule, but these are of rare occurrence; and where pain 
in the early stage of the disease is wanting, there is usually 
some derangement of the general health, weakness of the ex- 
tremities, or other symptoms, showing that the patient labours 
under some kind of disease, without indicating its exact nature 
and locality. 

In general, the curvature is at first only just perceptible, and, 
by degrees, it becomes more distinct. In one instance, a young 
woman who had made no previous complaints, immediately 
after some slight exertion, experienced a sensation as if some- 



160 ON CARIES OF THE SPINE. 

thing had given way in her back, and immediately afterwards 
lost the use of her lower limbs. This was followed by an an- 
gular projection of the spinous process of one of the inferior 
dorsal vertebrae, and a large abscess, which presented itself on 
one side of the abdomen : and the patient ultimately died. In 
another case, after the curvature had taken place, the form of it 
appeared to vary, in consequence of the diseased vertebrae ad- 
mitting of being moved to a certain extent on each other; these 
motions being attended with increased pain, both in the spine 
and in the lower extremities. The last-mentioned patient ul- 
timately recovered. 

Curvature of the spine in the direction forwards may arise 
from other causes, as a weak condition of the muscles, or a 
rickety affection of the bones. In general, in such cases, the 
curvature occupies the whole spine, which assumes the form of 
the segment of a circle. At other times, however, it occupies 
only a portion of the spine, usually that which is formed by the 
superior lumbar and inferior dorsal vertebrae; as I have ascer- 
tained, not only by examinations during life, but by dissection 
after death. Here the curvature is always gradual; never an- 
gular; and thus it may be distinguished from the curvature 
arising from caries. Nevertheless, I am satisfied that these 
different kinds of curvature, arising from different causes, have 
frequently been confounded with each other; and that some of 
the cases, which have been published as examples of caries of 
the spine, and in which it may, at first, be a matter of surprise 
that so complete and so speedy a cure should have been ef- 
fected, have in reality been cases of an entirely different ma- 
lady.* 

I have already mentioned, that there is reason to believe that 
suppuration takes place at an earlier period in those cases in 
which the disease has its origin in the cancellous structure of 
the bones, than where it begins in the intervertebral cartilages. 
It is remarkable, in some cases of this last description, to how 
great an extent ulceration will sometimes proceed, without the 
formation of abscess. 1 have known as many as three bodies 
of vertebrae completely destroyed, and the disease to have 
lasted many years, without matter having been formed: a for- 

* Some excellent observations on this subject have been published by Mr, 
Earle, in the Edinburgh Medical Journal for January, 1815. 



ON CARIES OF THE SPINE. 161 

tunate circumstance for the patient, as the chance of his reco- 
very is much greater under these, than it would have been un- 
der the opposite circumstances. We must not, however, con- 
clude, because no abscess has shown itself, that therefore no 
abscess exists. Frequently, in examinations after death, we 
find an abscess in connexion with carious vertebrae, which 
had never presented itself externally, but which evidently 
had existed for a considerable length of time. 

It is not uncommon to find caries of the vertebrae going on 
for two or three years before there are any certain indications 
of the existence of abscess. In one case, in which the disease 
was in the vertebrae of the loins, an abscess presented itself in 
the groin at the end of eight years; and in another case, in 
which the disease was situated in the dorsal vertebrae, the in- 
terval was still longer — not less than sixteen years. The for- 
mation of abscess is usually attended with some derangement 
of the general health, such as loss of flesh and muscular power; 
increased frequency of the pulse; a slight access of fever in 
the evening, followed by perspirations at night; occasionally, 
but rarely, rigors. 

These symptoms may be in some degree relieved by the 
first bursting of the abscess; but when the daily discharge of 
matter has continued for some time, they recur in an aggravated 
form: the patient wastes under the influence of a hectic fever, 
and some kind of visceral disease supervenes, which proves the 
immediate cause of death. 

The foregoing observations relate to cases of caries of the 
spine generally; but, to complete the history of the disease, it 
is necessary to consider the peculiar symptoms which it pro- 
duces, accordingly as one or another part of the column of the 
vertebrae is affected by it. 

When there is caries of the cervical vertebrae, the patient 
complains, in the first instance, of pain in the neck, which is 
aggravated by every motion of the head, and which is not un- 
frequently mistaken for the muscular pains and stiffness con- 
nected with what is commonly called a stiff neck from cold. 
The pain gradually increases, and, according to my experience, 
is more liable to be severe than when the seat of the disease is 
in the lower part of the spine. When in the progress of the 
disease, the spine has become incurvated forward, the angular 
projection posteriorly is observed to be trifling, except when 



162 ON CARIES OF THE SPINE. 

the lowest or seventh cervical vertebra is implicated in the dis- 
ease; a difference which is easily explained by the greater length 
of the spinous process of the latter, as compared with that of 
the spinous processes of the vertebrae above. 

Abscess connected with diseased cervical vertebrae usually 
presents itself among the muscles on the side of the neck. Oc- 
casionally it makes its way forward, forming a tumour, and 
afterwards breaking in -the pharynx. I have seen one case in 
which the abscess penetrated into the theca vertebralis, and the 
whole of the spinal chord, from its origin to its termination, 
was bathed in pus. At an early period of the disease, the pa- 
tient frequently complains of pains in the arms and shoulders. 
After some time these pains subside, but they are followed by 
complete paralysis of the upper extremities; while the muscles 
which derive their nervous influence from the spinal chord be- 
low the neck, remain subject to the will. In a still more ad- 
vanced stage of the disease, the paralysis extends to the muscles 
of the trunk and of the lower extremities, Then there are 
pains in the abdomen, which becomes distended and tympani- 
tic; the bowels being at the same time obstinately costive. In 
all cases, there is pain in the occiput and temples; which is, 
however, most severe when the disease is situated in the two 
or three superior vertebrae. Not unfrequently the transverse 
ligament of the second vertebrae is destroyed, and the conse- 
quence is, a dislocation of the odontoid process. Sometimes 
the dislocation is complete, and the patient, from the pressure 
made on the spinal chord, expires as suddenly as if the latter 
had been divided transversely. More frequently it happens 
that the displacement of the odontoid process is somewhat re- 
strained by the pressure of the dura mater which lies over it. 
There is then some degree of pressure on the spinal chord, 
sufficient to excite irritation, but not sufficient to destroy its 
functions. Under these circumstances, the patient complains 
of increased pain in the head, followed by convulsions, stupor, 
dilated pupils, anc) other symptoms of effusion of fluid on the 
brain; and on examining the body, after death, we find that such 
effusion has actually taken place, there being a collection of 
fluid in the ventricles, or in the base of the cranium, or in both 
of these situations. 

In cases of caries of the superior dorsal vertebra, indepen- 



ON CARIES OF THE SPINE. 163 

dently of the usual pain and tenderness of the affected parts, 
the patient complains of pain and a sense of constriction of the 
chest; and when the disease is in the inferior dorsal vertebrae, 
there is a similar sensation in the epigastrium, pain in the ab- 
domen generally, and a disturbed state of the functions of the 
alimentary canal. Occasionally the urine is alkaline, or it con- 
tains albumen, being voided without its natural transparency, 
and becoming opaque on exposure to heat, or on the addition 
of nitric acid. From this last circumstance, and from there 
being at the same time pain either in or near the region of the 
kidney, it is sometimes difficult, in the first instance, to deter- 
mine whether the patient labours under caries of the spine or 
disease of the kidney. 

When the spine is incurvated forward, in consequence of the 
destruction of the bodies of the dorsal vertebrae, the angular 
projection behind is more distinct than it ever is where the 
disease has attacked the vertebrae of the neck or loins. This 
is to be attributed to the greater length of the spinous processes 
in this part of the spine, and to the circumstance of their being, 
in the ordinary position of the parts, inclined more or less 
downwards. When the curvature is considerable, the thorax 
becomes at the same time altered in figure. The diameter of 
the thorax from above downwards, is rendered shorter, while 
the other diameters are increased; so that, while the figure of 
the chest is altered, there is but little difference in its actual 
capacity. If, under these circumstances, an opportunity should 
occur of examining the appearances after death, we find a change 
in the position of the viscera corresponding to the altered form 
of the cavity in which they are contained. This is most appa- 
rent in the descending aorta, which is seen taking a spiral, in- 
stead of its usual straight course on the fore part of the spine. 
When the superior dorsal and inferior cervical vertebrae are 
both implicated in the disease, a large protuberance presents 
itself between the superior angles of the scapulae, and the neck 
appears shortened, as if it had descended or sunk between the 
shoulders. 

As the disease advances, the patient, in some instances, com- 
plains of pains, which are referred to one groin and hip, such 
as may lead to the suspicion that there is disease in the hip-joint; 
and, in fact, it is a very common error (and one into which 



164 ON CARIES OF THE SPINE. 

even surgeons of great experience are liable to fall,) to regard 
the symptoms of caries of the middle and inferior dorsal ver- 
tebrae as indicating incipient caries of the hip. Afterwards 
pains and a sense of constriction, are felt in the legs and thighs. 
Then the muscles are found to be not properly under the 
dominion of the will, so that the patient occasionally loses a 
step, or trips in walking. This is probably followed by a com- 
plete loss of voluntary power. In some cases there is an entire 
paralysis; the muscles of the lower extremities never acting 
under any circumstances: while in other cases, although they 
do not act under the* influence of volition, they are subject to 
involuntary contractions or spasms. 

Occasionally the loss of voluntary power over the muscles 
is attended w T ith a total loss of sensibility; but more frequently 
while the former function of the nerves is destroyed, the latter 
remains either little or not at all impaired. 

Paralysis of the bladder, and incontinence of the urine and 
faeces, sometimes occur in combination with paralysis of. the 
lower limbs, forming a most distressing addition to the patient's 
other calamities. 

A considerable time generally elapses before abscess con- 
nected with caries of the dorsal vertebrae presents itself exter- 
nally. Sometimes it shows itself on the posterior or lateral, 
or even on the anterior part of the chest, having penetrated 
through one of the intervertebral spaces. More commonly it 
makes its way downwards through the posterior mediastinum, 
and behind the small muscle of the diaphragm; and then, taking 
the course of the psoas muscle, passes behind the crural arch, 
and shows itself in the anterior and upper part of the thigh. 
It is not uncommon for the abscess to form a large tumour on 
one side of the abdomen; occupying the whole, or a great part, 
of the space between the false ribs and the groin, pushing the 
viscera to the opposite side, and, at last, making its way to the 
surface, either through the abdominal muscles, or under Pou- 
part's ligaments. But a great length of time may elapse be- 
fore it reaches this termination. I have known such an abscess 
to remain neither increasing nor diminishing in size, nor being 
materially changed in its situation, for several successive years: 
in some instances being a soft and compressible tumour, in 
which the fluctuation of matter was distinctly perceptible; in 



OS' CARIES OP THE SPINE. 165 

others, appearing like an irregular mass of solid substance, 
closely attached to the posterior and lateral parts of the spine. 
Inexperienced surgeons not unfrequently mistake an abscess 
under the circumstances which I have just described, for an 
encysted tumour, or some other morbid growth. 

When the lumbar vertebrae are affected with caries, the pa- 
tient usually complains of pain in the region of the loins; which 
is aggravated by stooping, turning the body suddenly round, or 
by percussion. Sometimes the pain is confined to the vertebrae 
themselves; while at other times it extends forwards, in the di- 
rection of the lumbar nerves, to the sides of the abdomen and 
the crista of the ilium. 

When abscess is formed, it usually either descends in the di- 
rection of the psoas muscle, and presents itself behind the crural 
arch in the upper and anterior part of the thigh, or otherwise 
makes its way backwards on the outer edge of the quadratus 
lumborum and sacro-hunbalis muscles, showing itself on 'one side 
of the loins. In some rare cases, it takes the course of the sper- 
matic chord, and forms a tumour projecting through the abdomi- 
nal ring, such as a superficial observer might easily mistake 
for a hernia: or, it descends into the pelvis, and afterwards into 
the posterior part of the thigh, following the direction of the 
sciatic nerve, through the sacro-sciatic notch of the pelvis. Oc- 
casionally it reaches this last-mentioned 'situation in another 
way. I have known an abscess to have descended from the 
loins, and presented itself as a tumour in the groin. Suddenly 
the tumour has disappeared, and the patient has been led to en- 
tertain hopes of a speedy recovery. But these have been soon 
disappointed, in consequence of the discovery of a large collec- 
tion of matter in the posterior part of the limb, behind the little 
trochanter of the thigh. In a case of this kind, in which I had 
the opportunity of examining the morbid appearances after 
death, I found that the abscess had taken the course of the com- 
mon tendon of the psoas magnus and iliacus scles, to 
their insertion into the little trochanter, afterwards extending 
farther backward, over the inferior edge of the quadratus femoris. 

I may take this opportunity of observing, that it is by no 

means uncommon, whatever part of the spine may be the seat 

of caries, to find an abscess thus altering its course, disappearing 

in one place, and sometimes afterwards showing itself in another: 

15 



166 ON CARIES OF THE SPINE. 

and this seems to afford a reasonable explanation of some of 
those cases, in which it has been supposed that an abscess has 
been suddenly removed by absorption. 

It very rarely happens that this disease, when confined to the 
loins, proceeds so far as to occasion any perceptible alteration 
in the figure of the spine: and this peculiarity is easily ex- 
plained, by the greater magnitude of the bodies of the lumbar, 
as compared with those of the cervical or dorsal vertebrae, in 
consequence of which, the former are not destroyed by the 
same degree of caries which would be sufficient for the destruc- 
tion of the latter. 

The same circumstance will also, in great measure, account 
for another peculiarity of this disease, when it affects the lower 
portion of the spine; namely, the absence, in the majority of 
cases, of pains, muscular spasms, paralysis, and loss of sensibility 
in the lower limbs. In fact, in these cases it seldom happens 
that the caries extends so far as to reach the theca vertebralis. 
In one case, in which the patient had complained of numbness 
of the legs and thighs, I found, on dissection, that the theca ver- 
tebralis was in no part exposed; but that there was a large ab- 
scess on each side surrounding the origin of the anterior crural 
and obturator nerves, and thus explaining the diminished sen- 
sibility of the parts to which they were distributed. 

In systematic works on surgery, the lumbar or psoas abscess 
is usually described as if it were (in some instances at least) a 
specific or primary disease, having its origin in the psoas muscle. 
But, according to all the experience which I have had in these 
cases, this is altogether a mistaken view of the subject, I can- 
not say that such an abscess never takes place in the loins; but 
I certainly believe that it is of very rare occurrence. In ex- 
amining cases of lumbar abscess after death, I have always 
found caries of the vertebrae, in which the abscess has mani- 
festly originated. In general the disease of the vertebrae has 
been so obvious, that it could not have been overlooked by the 
most superficial observer; but, in some instances, the real na- 
ture of the disease has not been detected until after a careful 
dissection, in one instance, on examining the body of a patient 
who died in St. George's Hospital with an extensive suppura- 
tion in the loins, the soft parts having been entirely removed, 
not the smallest appearance of disease presented itself in the 



OX CARIES OF THE SPINE. 167 

lumbar vertebrae, and I conceived that I had at last met with 
a case of genuine psoas abscess; when, almost accidentally, a 
small opening was discovered on one side of the spine, in a 
part which had been covered by one of the attachments of the 
psoas muscle, just large enough to admit a common probe, and 
forming a communication between the cavity of the abscess, 
and one of the intervertebral spaces. On a farther dissection, 
it was ascertained that the intervertebral cartilage had been com- 
pletely destroyed by ulceration, except at its circumference, 
and that the opposite surfaces of the bodies of the two con- 
tiguous vertebrae were extensively carious. 



SECTION III. 

ON THE TREATMENT OF CARIES OF THE SPINE. 

There are few cases of caries of the spine in which it is not 
advisable to have recourse to some kind of medical treatment, 
for the purpose either of correcting that state of the system on 
which the local disease depends, or of counteracting the ill ef- 
fects which the latter has produced on the patient's general 
health. On this subject, however, it will be sufficient for me 
to refer to the observations which I have already offered in 
speaking of the treatment of the diseases of the other articula- 
tions, in the concluding part of each of the two preceding chap- 
ters. 

Of those remedies which may be supposed to exercise a more 
direct influence over the disease, the two which have been 
principally recommended are; first, a state of absolute rest in 
the horizontal position, continued during a considerable period 
of time; and, secondly, the establishment of issues made with 
caustic, or the actual cautery in the neighbourhood of the af- 
fected vertebrae. 

I suppose that no one will be bold enough to deny the pru- 
dence, and that few will deny the absolute necessity, of the 
first of these remedies. While the patient is in the erect pos- 
ture, and the weight of the head and other superincumbent parts 



168 ON CARIES OF THE SPINE. 

are pressing on the ulcerated surfaces, and while these are liable? 
in the various motions of the body, to a constant (however 
trifling) friction, it is not probable that the progress of ulcera- 
tion can be checked, or that suppuration can be prevented. 
From the first moment in which the nature of the case is clearly 
indicated, the patient should abandon his usual habits, and be 
confined altogether to his bed or couch. In some instances, in 
which severe pain in the vertebrae is among the early symp- 
toms of the disease, the patient will submit to the privations 
which are thus imposed upon him with sufficient willingness; 
while in others, nothing but a candid exposition of the ill con- 
sequences which may otherwise arise, will overcome his reluc- 
tance to do so. The invalid bedstead, contrived by Mr. Earle? 
and which I have formerly mentioned, will, in ordinary cases, 
afford the most convenient means of conducting this part of the 
treatment. The use of it is attended with this great advantage, 
that the patient may be laid on his back, and the trunk and 
thighs may be, from time to time, and within moderate limits, 
elevated or depressed, so that their relative position may be 
varied without the smallest movement being communicated to 
the carious vertebrae. Where, however, the disease has been 
<*oing on for a long time, and there exists already a considerable 
angular curvature of the spine, it is desirable that the patient 
should recline on hjs side rather than on his back; or if he finds 
this in any way inconvenient or disagreeable, he should lie, not 
on an absolutely flat surface, but supported by cushions and pil- 
lows, so that the position in which he is placed may have no 
tendency to restore the spine to its original figure. In the 
management of these cases, it is important that we should 
always bear in mind, that, without undue interference on the 
part of the surgeon, the carious or ulcerated surface of the ver- 
tebra above will come in contact with that of the vertebra be- 
low; and that it is to the union which takes place between 
them under these circumstances, at first by soft substance, and 
afterwards by bony anchylosis, that w T e are to look for the 
patient's recovery. In artificially straightening or elongating 
the incurvated spine, we necessarily disturb this curative pro- 
cess, and therefore all attempts to do so, whether by means of 
machinery, or by laying the patient in the supine posture on a 
horizontal board, are to b^scrupulously avoided. 



OX CARIES OF THE SPINE. 169 

The recumbent position does not constitute the only means 
which we have it in our power to employ for the purpose of 
maintaining the diseased spine in a state of perfect repose. 
When the disease is situated in the dorsal or lumbar vertebrae, 
the patient may be provided with a bandage, including some 
stripes of whalebone, and somewhat resembling the stays worn 
by females, but extending as low as the symphysis of the pubes, 
the os sacrum, and the great trochanter, and as high as the neck. 
This will operate like splints, fixing the pelvis and thorax in 
the same relative position, A less efficient support may be 
given to the cervical vertebrae by means of a cushion adapted 
to the shape of the lateral and posterior parts of the neck, and 
extending from the upper part of the back to the occiput. 

Concerning the advantage to be derived from the establish- 
ment of issues, there may probably be a greater diversity of 
opinion than concerning that which is to be obtained from rest 
and the recumbent posture; and 1 am well aware that some ex- 
perienced practitioners of the present day estimate their value 
at a low rate. It is not, however, easy to suppose that Mr. 
Pott and others, whose opinion carries with it much authority, 
should have been mistaken so far as to persevere, during a serie^ 
of years, in the employment of a remedy which was actually 
inefficacious. If issues are of service, where the cartilages of 
the hip or knee are ulcerated, analogy would lead us to expect, 
that they may be useful also, where a corresponding disease has 
taken place in the joints of the vertebras; and my own expe- 
rience has certainly tended to confirm this expectation. I have 
known instances of patients who have been under precisely the 
same circumstances with respect to rest, and whose symptoms 
have been manifestly and considerably relieved, either imme- 
diately or in a short time after the issues had been made; and, 
where the caustic has been occasionally applied to the surface 
of the issue for the purpose of keeping it open, other patients 
have informed me, that "they have uniformly found themselves 
better in a few hours after each application." At the same 
time it must be acknowledged that some cases occur in which 
the caustic issues seem to be productive of little or no benefit. 
Probably it is with diseases of the vertebral as it is with those 
of the other joints, and issues may be of little or no efficacy 
where the ulceration of the cartilages is preceded by a scrofu- 

15* * 



170 ON CARIES OF THE SPINE. 

lous disease of the cancellous structure of the bones; and they 
may be productive of great benefit where it takes place under 
other circumstances. Nor, if my observations on the subject 
be well founded, is this to be regarded as a merely theoretical 
opinion. I have repeatedly known the greatest relief to follow 
the establishment of issues, where the patient has suffered se- 
vere pain in the situation of the carious vertebrae, presenting at 
the same time no distinct indications of a scrofulous diathesis; 
while, in young persons, with fair complexions, and dilated 
pupils, in whom the disease has proceeded with little or no 
pain, they have appeared to be either inefficacious, or actually 
injurious. It appears to me, also, that in caries of the spine, as 
well as in that of other joints, issues are to be employed only 
in the early stage of the disease, with a view to prevent suppu- 
ration, and that they are of no service after abscess has actually 
formed. 

An important question remains: how long is the use of these 
remedies to be continued? It is often difficult to answer such 
an inquiry even in an individual case; and it is much more so 
to lay down a general rule on the subject. The issues may be 
healed on the first clear evidence of the formation of abscess; 
otherwise, if they occasion little or no inconvenience, they may 
be kept open for one or two years. With respect to the re- 
cumbent position, if there be a reason for having recourse to it, 
there is also a sufficient reason for it not being abandoned in 
less than six or seven months, even when the disease is in its 
earliest stage; and, in the great majority of cases, the period 
should be extended to a year, and sometimes to a year and a 
half. 

In the first instance, the surgeon usually finds it difficult to 
persuade the patient to continue this part of the treatment for 
a sufficient length of time after the removal of the more urgent 
symptoms. Afterwards, however, he often has to encounter a 
difficulty of an opposite kind. This happens especially among 
young females, who become at last so habituated to their couch, 
and the peculiar mode of life connected with it, that they can 
scarcely be persuaded to make the necessary effort to sit up and 
move about, even after every reason for not doing so has va- 
nished. I know an instance of a lady, who, under these cir- 
cumstances, has preserved the horizontal position for fourteen 



ON CARIES OF THE SPINE. 171 

years, and in whom nearly all the joints of the lower extremi- 
ties, in which no actual disease ever existed, have, from mere 
want of exercise, become firmly anchylosed; so that it is evi- 
dent that nothing which can now be done will enable her to 
regain the use oLthe limbs, or even to sit up. 

With respect to the treatment of abscesses connected with 
caries of the spine, I am not aware of any circumstances in 
which it should differ from that of abscesses connected with 
other joints affected by the same disease. The patient should 
not venture to take exercise, nor even to quit the recumbent 
posture until the abscesses are healed. This is to be regarded 
as the general rule; from which, however, on a very few occa- 
sions, it may be right to deviate. I was consulted by a gentle- 
man who was at that time thirty-five years of age, and who had 
laboured under well-marked symptoms of caries of the spine, 
since he was three years old. There was considerable curvature 
in the direction forward, with an angular projection of the spi- 
nous processes of the middle dorsal vertebrae posteriorly; and 
there were two sinuses, discharging pus, communicating with 
the carious vertebras, which had existed for nearly thirty years, 
Nevertheless, the patient had been able to take violent exercise 
in hunting and shooting, and other ways, and his general health 
had been excellent. In fact, he had suffered no material incon- 
venience from his complaint, except that he once lost the use 
of his lower limbs; recovering it, however, completely at the 
expiration of three months, and after the application of blisters 
to the back. 



CHAPTER VII. 

ON TUMOURS AND LOOSE CARTILAGES IN THE CAVITIES 

OF JOINTS. 

The loose cartilaginous substances, which are sometimes 
found in the joints, have been so frequently described by wri- 
ters, that I can have but few observations to offer respecting 
them. I believe it is generally supposed that these loose bodies 



172 ON TUMOURS AtfD LOOSE CHRTILAGES 

have their origin in coagulated lymph, which has been effused 
from inflammation of the inner surface of the synovial mem- 
brane, and which has afterwards become vascular. In the ma- 
jority of cases, however, which I have met with, no symptoms 
of inflammation preceded their formation; ai*d hence it is pro- 
bable that, in some instances, they are generated, like other 
tumours, in consequence of some morbid action of a different 
nature. 

They -appear to be situated originally either on the external 
surface, or in the substance, of the synovial membrane; since, 
before they have become detached, a thin layer of the latter 
may be traced to be reflected over them. 

My own experience is much in favour of the removal of 
these loose cartilages by an incision of the joint, provided that 
this be done in a cautious and prudent manner. The patient 
should be kept in a state of the most perfect quietude for two 
or three days preceding, and for several days after, the opera- 
tion. The cartilage having been well fixed, the different parts 
over it should be slowly and separately divided until it is ex- 
posed. The wound of the synovial membrane may be dilated 
by means of a probe-pointed bistoury, until it is of sufficient 
size to allow of the cartilage being extracted with a tenaculum ; 
and the cut edges of the skin should be instantly replaced in 
contact with each other, and secured by means of adhesive 
plaster, 

I attended a gentleman who laboured under this troublesome 
disease, and in whom the loose bodies not unfrequently slipped 
between the articulating surfaces of the knee, occasioning an 
almost immediate swelling of the joint, with the most excruci- 
ating pain and tenderness, and much symptomatic fever. In 
one instance, more than a month elapsed before these symptoms 
had subsided. These circumstances are noticed, because they 
prove that, in this patient, there was $. considerable disposition 
to inflammation; yet, by attending to the precautions above 
mentioned, as many as five loose cartilages were extracted by 
three different operations, without the slightest inconvenience 
arising from any one of them. 

1 have seen two cases, in which the loose bodies were of a 
different nature, and had a different origin from those which are 
commonly met with. It occasionally happens, that a bony ridge 



IN THE CAVITIES OF JOINTS. 173 

is formed, like small exostosis, round the margin of the carti- 
lages of the joint. In the two cases to which 1 allude, this pre- 
ternatural growth of bone had taken place, and in consequence 
of the motion of the parts on each other, portions of it had been 
broken off, and lay loose in the cavity of the joint. 



« In the museum of St. George's Hospital, there is a specimen 
of a knee-joint, the inner surface of which is lined by a great 
number of small pendulous excrescences, connected with the 
synovial membrane; having a smooth external surface, and 
bearing an apparent resemblance to the appendices epiploic^ of 
the great intestine, though not containing adipose substance. 
The preparation was purchased at the sale of the late Mr. Hea- 
viside's anatomical collection; and nothing is known of the 
history of the patient from whom it was taken. We have 
another somewhat similar specimen; and, in the last case, there 
is reason to believe that the excrescences were the result of 
long-continued inflammation of the synovial membrane. A 
third example of the same disease is in Sir Charles Bell's mu- 
seum, which was formerly in Great Windmill Street. The 
late Mr. Shaw informed me that, in this case, the joint contained 
a considerable quantity of whey-like fluid; but he was not able 
to give me any farther information respecting it. 

Occasionally, tumours of a different kind are formed on the 
inner surface of the synovial membrane, and attain a considera- 
ble magnitude. 

CASE LXVIII. 

Morris Sudbury, twenty-one years of age, was admitted into 
St. George's Hospital, on the 4th of October, 1820. 

He had swelling, and complained of pain and tenderness, in 
one knee. He was kept in bed: the joint was bathed with a 
cold lotion. Afterwards blisters were applied. The swelling 
subsided, but the joint continued weak and painful. 

On the 11th of December, for the first time, a tumour was 
discovered evidently within the cavity of the knee-joint, situ- 
ated on the edge of the patella, over the external condyle of the 
femur. The tumour appeared like a loose cartilage, of about 
the size and form of an almond. When the man attempted to 
walk, in certain motions of the limb, it slipped into the cavity 



174 ON TUMOURS AND LOOSE CARTILAGES 

of the joint, producing considerable distress, and making him 
lame. An attempt was made to confine it by means of ban- 
dages, but without success. 

On the 5th of January, 1821, Mr. Ewbank made an incision 
through the skin, fascia, and synovial membrane, so as to ex- 
pose the tumour. It was found to be not cartilaginous, but of 
a gristly structure. It was of about the length of an almond, 
but rather broader; and it was attached by one extremity to 
the synovial membrane, near the edge of the patella. This 
attachment was cut through, and the tumour was removed. 
The edges of the wound were brought into contact, and united 
by the first intention. Some inflammation of the joint followed, 
but was subdued without much difficulty. When the patient 
began to walk, he found himself to have been much relieved by 
the operation. 

Six weeks afterwards, however, a tumour was discovered in 
the knee of a smaller size than that which had been removed, 
but occupying precisely the same situation; so that there was 
sufficient reason to believe that it had grown from the same 
basis. This tumour could be pressed into the joint by the 
fingers, but did not slip into it spontaneously in walking; and 
therefore, at the time when the man left the hospital, he did 
not suffer any inconvenience from it. 

CASE LXIX. 
Mr. H., a young man, consulted me on the 25th of April, 
1822, labouring under the following symptoms: — In certain 
motions of the right knee a tumour presented itself on the in- 
side of the patella, which had been supposed to be, and had the 
appearance of being, a loose cartilage of a large size. He said 
that, occasionally, in walking, this substance slipped between 
the articulating surfaces. The accident always produced con- 
siderable pain at the time, and inflammation of the synovial 
membrane afterwards, which in one instance confined him to 
his bed for several weeks. . He said, farther, that these symp- 
toms had been gradually coming on for two or three years ; 
that he had worn bandages, without experiencing any good 
effect; and that, as the disease interfered very much with his 
comfort and occupations, he was desirous of submitting to any 
operation which afforded him a prospect of relief. 



IN THE CAVITIES OF JOINTS. 175 

On the 28th of April, after he had remained for one or two 
days in a state of perfect quietude, I carefully made an incision 
on the tumour, which had been previously fixed by the finger 
of an assistant over the inner condyle of the femur. When it 
was thus exposed, I found the tumour to be, not a loose carti- 
lage, but of a fleshy structure; and that it was connected to the 
synovial membrane, below the patella, by a broad adhesion. 
Having divided this adhesion, I removed the tumour. The 
edges of the wound were brought together by means of a suture, 
which was passed through the integuments, and stripes of ad- 
hesive plaster. The patient w T as kept in bed, and the limb was 
supported by a splint, to which it was secured by bandages in 
such a way as to render the joint quite incapable of motion. 

About twenty-two hours after the operation, symptoms of 
violent inflammation began to show themselves. There was 
almost insupportable pain; the joint became rapidly swollen: 
the pulse rose to 90 in a minute, and was hard and strong. By 
means of very active antiphlogistic treatment, however, the in- 
flammation subsided, without producing any bad consequences. 
On the 27th of June he was able to undertake a journey to a 
considerable distance from London; at which time the knee 
was neither swollen nor painful, but it was still incapable of 
perfect flexion and extension. Since then the patient ha.* re- 
covered the perfect use of the joint. 

On examining more accurately the tumour "which had been 
removed in this case, it was found to be about two inches and 
a half in length, and one inch and a half in breadth, and some- 
what less than half an inch in thickness in the thickest part; 
convex on one surface, and somewhat flattened on the other. 
It was of a firm, fleshy structure. The general appearance of 
it a good deal resembled that of the coagulum which is found 
in the sac of aneurism; but it was not laminated: it had a smooth 
membranous surface; and it was manifestly organized, as vessels 
might be distinctly trared ramifying through its substance.* 

* A remarkable circumstance occurred in the progress of this case. The 
wound made in the operation united by the first intention; but the joint being 
much distended with synovia, the adhesion gave way; so that the wound 
was re-opened on the ninth or tenth day, and the synovia escaped in a small 
but constant stream. The discharge of synovia continued; but the joint being 
carefully retained in a state of the most perfect quietude, supported on a 
splint, no additional inflammation of it was the consequence. At last the 



176 ON MALIGNANT DISEASES 

In both of these cases the operation was resorted to under 
the impression that the substance contained in the cavity of the 
joint was one of the loose cartilages, of which I have spoken in 
the beginning of this chapter. If I had been acquainted with 
the real nature of the tumour in the last case, I should certainly 
have been less inclined to attempt its extirpation; and the vio- 
lence of the inflammation which ensued must form an additional 
reason for hesitation in any future case of the same kind. 

But the question will arise, how are such firm fleshy tumours? 
which are capable of altering their position in the cavity of a 
joint, and which produce symptoms similar to those which are 
produced by loose cartilages, to be distinguished from the latter? 
Perhaps, being aware of the possibility of the existence of a 
tumour of this description, we may, by a very careful exami- 
nation, be enabled to ascertain, even through the superjacent 
soft parts, that it has not the same degree of hardness with car- 
tilage itself. I am not at present acquainted with any other 
circumstances on which our diagnosis can be founded. Fortu- 
nately, however, it happens, that while loose cartilages in joints 
are not uncommon, such fleshy tumours as I have just described 
are of very rare occurrence. 



CHAPTER VIII. 



ON MALIGNANT DISEASES OF THE JOINTS. 

It is well known to surgeons that the bones are liable to 
those morbid growths and alterations of structure, which, from 
the peculiar circumstances which mark their progress, are 
usually denominated malignant diseases. 

In the cases which have fallen under my observation, carci- 
noma of the bones has never occurred as a primary disease, but 

flow of synovia ceased; the wound gradually closed; and in the course of three 
or four weeks it was firmly cicatrised. The same thing happened, under my 
observation, in another case, after the removal of loose cartilage from the 
knee. 



IN THE CAVITIES OP JOINTS. 177 

has always been preceded by carcinoma of the breast or some 
other glandular organ. The existence of the disease in the 
bones has been indicated by pains, sometimes slight, at other 
times most severe, resembling those of deep-seated rheumatism, 
but not yielding to the use of the remedies by which rheumatic 
pains are usually influenced. In these cases, the bones them- 
selves become unnaturally brittle, and are so easily broken, that 
I have more than once known a fracture of the femur to be pro- 
duced by the patient accidentally turning herself in bed; and, 
in one instance, a fracture of the clavicle took place on the pa- 
tient making some slight effort in raising her arm. 

Of the two following cases the first affords an example of 
carcinomatous disease affecting the head of the femur, and pro- 
ducing symptoms somewhat corresponding to those of disease 
in the hip-joint; while the second displays the symptoms which 
it produces when it attacks the vertebrae, and which are such 
as might lead a superficial observer to mistake the case for one 
of caries of the spine. 

CASE LXX. 

A lady between sixty and seventy years of age, in the year 
1817, underwent the operation for the removal of a scirrhous 
breast. Some time afterwards a hard tumour showed itself in 
the cicatrix; and, about the same period, she began to complain 
of pain in the left hip and thigh. On the 7th of November, 
1820, I saw her in consultation with Mr. Smith, surgeon, of 
Richmond, by whom she was attended. At this time a large 
scirrhous tumour occupied the situation of the breast which 
had been amputated. She complained of pain in the hip, 
thigh, and knee, which was aggravated by pressure: the pain 
was very severe, keeping her awake at night, except when she 
was under the influence of a very large dose of opium. There 
was a cluster of enlarged glands in the groin, making a hard, 
and somewhat moveable tumour. On the 18th of December 
following, the patient died; and the body was examined by Mr, 
Smith and myself on the following day. 

We found that the thigh-bone had been broken transversely 
about two inches below the neck; and it was evident, from the 
appearance of the fracture, that it had taken place either imme- 
diately before or after death; and, in either case, it must have 
I 16 



178 ON MALIGNANT DISEASES 

been the result of some very trifling accident The whole of 
the superior extremity of the thigh-bone was softer and more 
brittle than natural: but this morbid change was less distinct 
below than above the fracture, and it was more distinct in that 
part of the head of the bone which was contiguous to the car- 
tilage. On making a section of the head and neck of the bone, 
the earthy matter was found to be very deficient, and a carti- 
laginous or gristly substance was seen blended with the bony 
structure. In several places there were spots of increased vas- 
cularity with a deposition of some cheesy matter in the centre. 
The cartilages were not ulcerated, and there was no effusion of 
pus, lymph, or serum into the cavity of the joint. The enlarged 
inguinal glands had the structure of scirrhus; and there was a 
similar mass of scirrhous lymphatic glands in the pelvis, im- 
mediately above the crural arch. 

CASE LXXI. 

A lady about thirty-eight years of age consulted me, in the 
spring of 1832, on account of a scirrhous disease of one breast. 
There was not a distinct scirrhous tumour imbedded in the 
substance of the breast, but a conversion of the gland itself into 
the scirrhous structure. The skin covering the breast was 
thickened, and manifestly contaminated by the disease. 

From this time I saw her occasionally; the disease in the 
breast making little or no apparent progress. 

During the night of the 10th of February, 1833, she sudden- 
lv became paralytic in the whole of the lower part of the per- 
son. She not only lost the power of using her lower limbs, 
but that of voiding her urine also; and it became necessary to 
empty the bladder by means of a catheter. 

The loss of muscular power was attended with a loss of sen- 
sibility as high as the navel and lowest dorsal vertebrae. When 
the catheter was introduced into the bladder she was not sen- 
sible of its introduction. 

In the beginning of March the lower limbs became affected 
with involuntary convulsive movements, which were unattend- 
ed by pain, but of wbich the patient complained that it was dis- 
agreeable for her to see them. 

When the paralysis first took place the urine was clear, and 
otherwise in a natural state, afterwards it became ammoniacal, 



OF THE JOINTS. 179 

and offensive to the smell, depositing a thick mucus, with 
traces of phosphate of lime in it. 

On the 9th of April, 1S33, the patient died. 

The body was examined by Mr. Cutler, who found the 
whole of the gland of the breast to have assumed a scirrhous 
structure. 

Several of the dorsal vertebrae were converted into a sub- 
stance possessing considerable vascularity, of a gristly consis- 
tence; some of them containing no earthy matter whatever, so 
that they could be cut with a knife. Altogether, the alteration 
in the condition of the vertebrae seemed to be very similar to 
that which had taken place in the head of the femur, in the 
case which was last described, except that being more complete, 
it might be supposed to indicate a more advanced stage of the 
disease. 

The whole of the lower portion of the theca vertebralis w T as 
filled with a serous fluid. 

There was a deposite of earthy matter in the upper part 
of each lung; and about four ounces of serous fluid were con- 
tained in the cavity of the right pleura. 

The kidneys were of a dark colour, and highly vascular. 

The mucous membrane of the bladder bore marks of con- 
siderable inflammation. The ureters pelves, and infundibula 
of the kidneys were also inflamed, and in some parts lined with 
coagulated lymph. They w T ere considerably dilated, and con- 
tained a putrid mixture of urine and mucus. 

The bones are much more liable to be affected by fungus 
haematodes than they are by carcinoma; and the former fre- 
quently occurs in them as a primary disease, that is, not having 
previously shown itself in any other part of the body. Several 
cases have fallen under my observation, in which a tumour of 
this description has had its origin in one of the bones of a joint: 
and it is evident that such a tumour, in its progress affecting 
the contiguous parts, must, by degrees, render the joint use- 
less, and terminate in its complete destruction. 

In these cases the patient first complains of a slight degree of 
pain in the affected part, which is somewhat aggravated by ex- 
ercise. Some time afterwards the bone is observed to be 
slightly enlarged. As the tumour increases it is found to be 
elastic in some parts, hard in others. For a considerable time 



180 ON MALIGNANT DISEASES 

it does not interfere with the functions of the joint; which, 
however, afterwards becomes limited in its motions, and, ulti- 
mately, completely fixed in one position. I have known only a 
single case in which the patient did not submit to amputation 
before the disease had reached its most advanced stage; and here 
the skin became ulcerated, and a large ill-conditioned sore was 
the consequence. 

Amputation is, indeed, the only remedy which the surgeon 
has to offer; and it is unnecessary to say, that, in all cases of 
fungus hsematodes, even this is of doubtful efficacy. In the first 
of the two following cases I had, however, the satisfaction of 
learning that the patient continued well at the end of more 
than four years after the operation. 

CASE LXXII. 

Mr. 0., twenty-five years of age, in January, 1828, first ex- 
perienced a sensation of weakness in the right knee, with a 
slight pain, after walking even a short distance. These symp- 
toms continued; and, in the course of two or three months, he 
observed a small tumour over the external condyle. He re- 
mained in this state, the tumour not increasing in size, through 
the spring, and the greater part of the summer-. 

In the middle of the following August, he one day went 
through a great deal of fatigue in grouse-shooting; after which 
the tumour began to increase in size. 

On the 1st of September, in walking over a field, his foot 
slipped into a hollow in the ground. This caused great pain 
in the knee, and he was under the necessity of riding home. 
After this accident the tumour progressively increased in size. 

On the 25th of January, 1829, he came to London, and placed 
himself under the care of Mr. Griffiths, of Pimlico, and my- 
self. At this time, there was a very considerable enlargement 
of the whole of the upper part of the knee-joint, so that it was 
four inches in circumference larger than the corresponding part 
of the opposite limb. The tumour was soft and elastic, oc- 
cupying the situations of both condyles of the femur, but being 
more especially prominent in that of the outer condyle. The 
head of the tibia and the patella did not seem to be implicated 
in the disease, and the joint retained nearly its natural degree 
of mobility. 



OF THE JOINTS. 181 

For some time after I was consulted the tumour remained 
nearly stationary: then it began to increase; and, as no remedy 
seemed to have any dominion over the disease, a consultation 
was held with Sir Astley Cooper, in which it was determined 
that the limb should be removed by amputation. The opera- 
tion was accordingly performed on the 6th of July, 1829. 

On examining the amputated limb, the femur was found to 
terminate abruptly about five inches above the knee-joint. In 
place of the condyles and lower part of the shaft cf that bone, 
there was a large tumour, of an irregular form, the structure of 
which bore a nearer resemblance to that of fungus haematodes 
than of any other morbid growth. The cartilage which had 
covered the surface of the condyles of the femur was seen ex- 
panded over the lower part of the tumour; being every where 
thinner than natural, but no where in a state of ulceration. In 
some parts it had contracted adhesions to the cartilage covering 
the head of the tibia. 

In other parts the tumour was covered by some thin remains 
of the periosteum, and a layer of thickened cellular membrane. 

CASE LXXIII. 

William Williamson, fourteen years of age, was admitted 
into St. George's Hospital, on the 21st of September, 1831, on 
account of a tumour on the inside of the right knee, extending 
from about two inches below the tubercle of the tibia upward, 
over the inner condyle of the femur, as high as one-fourth of 
that bone, and backward so as to occupy the ham. The boun- 
daries of the tumour were distinctly defined. It seemed to 
have had its origin in the head of the tibia, and the tendons of 
the inner ham-string were seen stretched over its surface at the 
upper part, and apparently terminating in it below. The cir- 
cumference of the knee-joint, in the situation of the tumour, 
was eighteen inches. The skin covering the tumour was tense 
and shining, with large tortuous veins ramifying in it. 

On examining it with the hand, some parts of the tumour 
were found to be hard, while others were soft and elastic. 

The joint admitted of some degree of motion, but was kept 
in the half-bent position. The tibia appeared to be the only 
bone implicated in the disease. 

The patient had, generally, had good health; and seemed to 

16* 



182 ON SOME OTHER DISEASES 

be free from all other disease at the time of his being admitted 
into the hospital. 

He stated that, in April, 1831, he first experienced a slight 
degree of pain in the head of the tibia, especially in walking. 
About six weeks afterwards he observed a slight enlargement 
of the bone, which from that time gradually increased. 

September 29. The limb w r as amputated. 

On examining the knee-joint, the tumour was found to be 
wholly formed by an expansion of the head of the tibia. The 
upper and inner part of the tumour was composed, partly of 
cysts containing a bloody fluid, and partly of organized me- 
dullary substance. In other parts there was a mass of bony 
and cartilaginous substance, disposed in fibres, which seemed 
to proceed from what had been the surface of the original 
bone, and presented a somewhat radiated appearance. The 
other bones, the cartilages, and the soft parts composing the 
joint, were in a natural state. 



CHAPTER IX. 



ON SOME OTHER DISEASES OF THE JOINTS. 

In the present chapter it is proposed to notice some other 
diseases of the joints, which have not been described in the 
former pages. 

1. In those numerous cases in which acute inflammation at- 
tacks the shaft of a cylindrical bone and the periosteum cover- 
ing it, the disease is usually limited by the epiphyses; so that, 
notwithstanding the extensive abscesses and exfoliations which 
frequently ensue, the neighbouring joints are not affected by it. 

A few instances, however, occur, in which acute inflammation 
attacks the epiphysis itself, terminating also in more or less ex- 
tensive exfoliation. Sometimes we find nearly the whole of 
the epiphysis deprived of its vitality; at other times only one 
small portion of it, or several small portions in different places. 



OF THE JOINTS. 183 

In some of these cases, the exact nature of the disease is suf- 
ficiently obvious; but in others, where the exfoliations are of a 
very small size, it is difficult, or impossible, to form an exact 
diagnosis. This is, however, of the less importance, as, under 
all circumstances, such a disease must terminate in the com- 
plete destruction of the joint; so that there is no remedy but 
amputation. 

2. Chronic inflammation, producing a chronic enlargement 
of the epiphysis, is a not unfrequent occurrence, and is liable 
to be mistaken for disease in the joint itself; the more so, as in- 
flammation of the synovial membrane sometimes occurs as a 
secondary disease. The patient, under these circumstances, 
may derive benefit from the use of sarsaparilla, mercury, the 
hydriodate of potash, mezereon, or from the application of 
• blisters; in short, from any of those remedies which are found 
to be useful where nodes are formed in other parts of the 
bones. 

Occasionally chronic inflammation of an epiphysis terminates 
in the formation of an abscess in the centre of the bone, but 
contiguous to the joint. An abscess of this kind is attended 
with an extraordinary degree of suffering, such as not only 
justifies amputation, but induces the patient cheerfully to sub- 
mit to the operation. Under certain circumstances, however, 
he may obtain the desired relief without the loss of the limb, 
The following cases will serve to illustrate both the history and 
the treatment of these cases, and will be found interesting to 
the practical surgeon.* i 

CASE LXXIV. 

Mr. P., about twenty-four years of age, consulted me in Oc- 
tober, 1824, under the following circumstances: — 

There was a considerable enlargement of the lower extremity 
of the right tibia, extending to the distance of two or three 
inches from the ankle joint. The integuments at this part were 
tense, and they adhered closely to the surface of the bone. 

The patient complained of a constant pain, referred to the 
enlarged bone and neighbouring parts. The pain was always 
sufficiently distressing;- but he was also liable to more severe 
paroxysms, in which his sufferings were described as most ex- 

* These cases formed the subject of a paper which I formerly communi- 
cated to the Medico-Chirurgical Society, and which has been published in the 
17th volume of their Transactions. 



184 ON SOME OTHER DISEASES 

cruciating. These paroxysms recurred at irregular intervals, 
confining him to his room for many successive days, and being 
attended with a considerable degree of constitutional disturb- 
ance. Mr. P. described the disease as having existed more 
than twelve years, and as having rendered his life miserable 
during the whole of that period. In the course of this time 
he had been under the care of various surgeons, and various 
modes of treatment had been resorted to without any perma- 
nent advantage. The remedies, which I prescribed for him, 
were equally inefficacious. Finding himself without any pros- 
pect of being relieved by other means, he made up his mind 
to lose the limb by amputation; and Mr. Travers having seen 
him with me in consultation, and having concurred in the opi- 
nion that this was the best course which could be pursued, the 
operation was performed accordingly.* 

On examining the amputated limb, it was found that a quan- 
tity of new bone had been deposited on the surface of the lower 
extremity of the tibia. This deposition of new bone was ma- 
nifestly the result of inflammation of the periosteum at some 
former period. It was not less than one-third of an inch in 
thickness; and, when the tibia was divided longitudinally with 
a saw, the line at which the new and old bone were united 
with each other was distinctly to be seen. 

The whole of the lower extremity of the tibia was harder 
and more compact than under ordinary circumstances, in con- 

> * It is right that I should state briefly the termination of the case; especially 
as the circumstances attending it were probably connected with a peculiar 
condition of the nervous system, occasioned by the long continuance of the 
local disease. Unfortunately I preserved no notes of this part of the case at 
the time; but 1 have no doubt that my recollection is accurate as to the fol- 
lowing particulars. The patient bore the operation with the utmost fortitude, 
but immediately afterwards he was observed to become exceedingly irritable, 
restless, and too much disposed to talk. Unfortunately, in the evening, there 
was hemorrhage from the stump : which ceased, however, on the removal of 
the dressings and coagulum. During the night he had no sleep; and on the 
following day he was restless and incessantly talking, with a rapid pulse. 
These symptoms became aggravated. There was no disposition to sleep, and 
the pulse became so rapid that it could be scarcely counted. Until the third 
or fourth day the tongue remained clean and moist. After this period it be- 
came dry, and somewhat brown, and there was constant delirium. The pu- 
pils were widely dilated, and the sensibility of the retina was totally destroyed; 
the glare of a candle not being perceptible even when held close to the eye. 
Death took place on the fifth day after the operation. No morbid appearances 
were observed in the post mortem examination. 



ON THE JOINTS. 185 

sequence, as it appeared, of some deposite of bone in the can- 
cellous structure; and in its centre, about one-third of an inch 
above the ankle, there was a cavity of the size of an ordinary 
walnut, filled with a dark-coloured pus. The bone immediately 
surrounding this cavity was distinguished from that in the neigh- 
bourhood by its being of a whiter colour, and of a still harder 
texture, and the inner surface of the cavity presented an ap- 
pearance of great vascularity. The ankle-joint was free from 
disease. 

It seems highly probable that, if the exact nature of the dis- 
ease had been understood, and the bone had been perforated 
with a trephine, so as to allow the pus collected in its interior 
to escape, a cure would have been effected, without the loss of 
the limb, and with little or no danger to the patient's life. 
Such, at least, was the opinion which the circumstances of the 
case led me to form at the time; and I bore them in my mind, 
in the expectation that, at some future period, I might have 
the opportunity of acting on the knowledge which they af- 
forded me, for the benefit of another patient. 

CASE LXXV. 

Mr. B., at that time twenty-three years of age, consulted me 
in the beginning of February, 1S26. There was considerable 
enlargement of the right tibia, beginning immediately below 
the knee, and extending downwards, so as to occupy about one- 
third of the length of the bone. 

Mr. B. complained of excessive pain, which disturbed his 
rest at night, and some parts of the swelling were tender to 
the touch. The knee itself was not swollen, and its motions 
were perfect. 

He said that the disease had begun more than ten years ago, 
with a slight enlargement and pain in the upper extremity of 
the tibia; and that these symptoms had gradually increased up 
to the time of my being consulted. Various remedies had been 
employed, from which, however, he had derived little or no 
advantage. 

Having inquired into the circumstances of the case, I was 
led to regard it as one of chronic periostitis; and I adopted the 
following method of treatment: — An incision was made longi- 
tudinally on the anterior and inner part of the tibia, extending 



186 ON SOME OTHER DISEASES 

from the knee four inches downwards, and penetrating through 
the periosteum into the substance of the bone. The periosteum 
was found considerably thickened, and the new bone, which 
had been deposited beneath, was soft and vascular. The im- 
mediate effect of the operation was to relieve the pain which 
the patient suffered, so that he slept well on the next and every 
succeeding night. After this I prescribed for him a strong 
decoction of sarsaparilla. The wound gradually healed; and it 
was for some time supposed that a perfect cure had been accom- 
plished. The enlargement of the upper extremity of the tibia, 
however, never entirely subsided; and in August, 1827, pain 
was once more experienced in it. At first the pain was trifling, 
but it gradually increased; and when I was again consulted, in 
January, 1828, Mr. B. was unable to walk about, and quite 
unfit for his usual occupations. At this period the pain was 
constant, but more severe at one time than at another, often 
preventing sleep during several successive nights. The en- 
largement of the tibia was as great as when 1 was first consulted; 
and the skin covering it was tense, and adhering more closely 
than is natural to the surface of the bone. Some remedies 
which I prescribed were productive of no benefit. The pa- 
tient's sufferings were excruciating, and it was necessary that 
he should, if possible, obtain immediate relief. The resem- 
blance between the symptoms of this case and those of the case 
already described was too obvious to be overlooked. It ap- 
peared highly probable that they depended on the same cause; 
and I therefore proposed that the bone should be perforated 
with a trephine, in the expectation that an abscess would be 
discovered in its interior. To this the patient readily as- 
sented; and, accordingly, the operation was performed in the 
beginning of March, 1828. 

My attention was directed to a spot about two inches below 
the knee, to which the pain was especially referred. This part 
of the tibia was exposed by a crucial incision of the integu- 
ments. The periosteum now was not in the same state as at 
the time of the former operation : it was scarcely thicker than 
natural, and the bone beneath was hard and compact. A tre- 
phine of a middle size was applied, and a circle of bone was 
removed, extending into the cancellous structure, but no ab- 
scess was discovered. I then, by means of a chisel, removed 



OF THE JOINTS. 187 

several other small portions of bone at the bottom of the cavity 
made by the trephine. As I was proceeding in this part of the 
operation, the patient suddenly experienced a sensation, which 
he afterwards described as being similar to that which is pro- 
duced by touching the cavity of a carious tooth, but much more 
severe, and immediately some dark-coloured pus was seen to 
issue slowly from the part to which the chisel had been last 
applied. This was absorbed by a sponge, so that the quantity 
of pus w^hich escaped was not accurately measured; but it ap- 
peared to amount in all to about two drachms. From this in- 
stant the peculiar pain belonging to the disease entirely ceased, 
and it has never returned. The patient experienced a good 
deal of pain — the consequence of the operation — for the first 
twenty-four hours; after which there was little or no suffering. 
The wound was dressed lightly to the bottom with lint; nearly 
six months elapsed before it was completely cicatrised; but, in 
about three months from the day of the operation, Mr. B. was 
enabled to walk about and attend to his usual occupations. He 
continued well when I last saw him, on the 7th of January, 
1S32 ; and the tibia was then reduced in size, so as to be scarcely 
larger than that of the other leg. No exfoliation of bone had 
ever taken place. 

CASE LXXVI. 

In the beginning of January, 1830, Mr. S., thirty-four years 
of age, consulted me on account of the following symptoms: — 

The lower extremity of the left tibia was considerably en- 
larged; the skin covering it was tense, and adhered closely to 
the parts below. He complained of a constant aching pain, 
which he referred to the enlarged bone. Once in two or three 
weeks there was an attack of pain more severe than usual, 
during which his sufferings were excruciating, lasting several 
hours, and sometimes one or two days, and rendering him alto- 
gether incapable of following his usual occupations. The pain 
was described as shooting and throbbing, worse during the night, 
and attended with such exquisite tenderness of the parts in the 
neighbourhood of the ankle, that the slightest touch w T as in- 
tolerable. 

Mr. S. said, that, to the best of his recollection, the disease 
had begun eighteen years ago, in the following manner: — On 
going to bed one evening, he suddenly experienced a most acute 



188 ON SOME OTHER DISEASES 

pain in the inner ankle. On the following morning he was 
unable to put his foot to the ground, on account.of the agony 
which every attempt to do so occasioned. Leeches were ap- 
plied several times, and afterwards blisters; but the pain in- 
creased notwithstanding. After some weeks an abscess pre- 
sented itself, and broke. This was followed by some mitiga- 
tion of the symptoms. Soon afterwards another abscess formed, 
and broke in the neighbourhood of the first. The tw T o abscesses 
remained open for a considerable time, and then healed rapidly. 
Mr. S. now began to regain the use of his limb, and, by de- 
grees, was able to w T alk as usual. 

During the following summer he had a recurrence of pain in 
the inner ankle, without any farther formation of abscess. For 
eight or ten years afterwards there were occasional attacks of 
pain, lasting one or two days at a time; the intervals between 
them being of various duration, and, in one instance, not less 
than nine months. After this the attacks recurred more fre- 
quently; and, during the whole of the last two years, the symp- 
toms were nearly as severe as at the time of my being con- 
sulted. 

On examining the limb, 1 was struck with the resemblance 
which it bore to that of the limb in each of the two preceding 
cases. There was also a remarkable resemblance in the symp- 
toms as described by the patient, and I could not but suspect 
that they depended on a similar cause. I requested that Mr. 
Travers, who had attended one of the former cases with me, 
should be consulted; and he agreed with me in the opinion, 
that probably an abscess existed in the centre of the tibia, and 
that it would be abvisable to perforate the bone with a tre- 
phine, with the view of enabling the contents of the abscess to 
escape. 

Accordingly, I performed the operation, with the assistance 
of Mr, Travers, on the 31st of January. A crucial incision 
was made through the skin, the angles of which were raised, so 
as to expose a part of the bone above the inner ankle, to which 
the pain was especially referred. A small trephine was then 
applied, and a circular portion of bone was removed, extending 
into the cancellous structure. Other portions of bone were re- 
moved with a narrow chisel. At last, about a drachm of pus 
suddenly escaped, and rose into the opening made by the tre- 



OF THE JOINTS. 189 

phine and chisel, On farther examination, a cavity was dis- 
covered, from which pus had flowed capable of admitting the 
extremity of the finger. The inner surface of this cavity was 
exquisitely tender, the patient experiencing the most excru- 
ciating pain on the gentlest introduction of the probe into it. 

He passed a tolerable night, and suffered but little on the fol- 
lowing day. He continued to go on favourably until the 5th 
of February, when a violent inflammation attacked the limb 
immediately above the inner ankle. In spite of the application 
of leeches, an abscess formed, which, in the course of six or 
seven days, presented itself immediately below the part at 
which the trephine had been applied. An opening was made 
with a lancet, and a considerable quantity of pus escaped, which 
had apparently formed between the periosteum and bone; the 
latter being felt exposed at the bottom of the abscess. During 
the following month the inflammation excited by the operation 
continued, and several abscesses presented themselves in the 
neighbourhood of the first. These, however, all healed favour- 
ably without any exfoliation of bone taking place. The cavity 
made by the trephine became filled up by granulations, and the 
wound gradually cicatrised. From the time of the operation, 
the peculiar pain, from which the patient had previously suf- 
fered, was entirely relieved; and it was not long before he was 
quite restored to health, and able to walk and pursue his occu- 
pations without interruption. When I last saw him, nearly 
two years from the time of the operation having been per- 
formed, he continued well. 

Since the three foregoing cases were published, first in the 
Medico-Chirurgical Transactions, and afterwards in the third 
edition of this treatise, I have performed a similar operation on 
a lad, a patient in St. George's hospital. The low T er extremity 
of the tibia was much enlarged, and he had suffered a constant 
and most severe pain for a very considerable time. On the ap- 
plication of the trephine I exposed an abscess in the centre of 
the tibia, containing three or four drachms of healthy pus. The 
relief was immediate and complete, and the subsequent recovery 
from the effects of the operation was rapid." It seems to be un- 
necessary to enter more particularly into the history of this 
case, after having given the details of the former ones. 

3. Absorption of the articular cartilages, to a limited extent, 
17 



190 ON SOME OTHER DISEASES 

sometimes takes place by a process apparently different from 
that of ulceration. The bone becomes partially denuded, but it 
bears no marks of inflammation; there is no erosion of the bony 
surface itself; and the cartilage, which remains entire, retains its 
natural adhesion to it. The patient does not complain of pain 
in the joint, nor does suppuration follow. These changes are 
, observed more frequently in the joints of elderly persons; and 
they are sometimes discovered after death, where their exis- 
tence had not been suspected during the patient's lifetime. At 
other times, they produce in the motions of the limb a grating, 
corresponding to, but less distinct than the grating which is 
perceptible after a fracture. 

4. The absorption of the cartilage which has been just de- 
scribed is not, however, the only cause of grating or crackling 
produced by the motions of the joints. This symptom is some- 
times manifestly connected with inflammation of the synovial 
membrane; at other times it occurs, as far as we can see, inde- 
pendently of any other disease, and it is then difficult to offer 
a reasonable explanation of it. The following case will serve 
to illustrate this last observation. 

CASE LXXVII. 

A married lady, apparently not more than twenty-six or 
twenty-seven years of age, in October, 1834, having been then 
a good deal weakened, in consequence of her having suckled 
her infant for eleven months, observed a grating or crackling 
to be produced by certain motions of the left knee. This was 
.not preceded by either pain or swelling, and neither pain nor 
swelling followed. Blisters were applied by the surgeon who 
attended her, but with no other result than a sensation of weak- 
ness in the limb, so that she could scarcely walk. Still there 
was neither pain, nor stiffness, nor swelling. After three or 
four months she had so far recovered from the effects of the 
blisters as to be able to walk; but the crackling was undimi- 
nished. 

When I saw the patient in August, 1835, she was free from 
pain; the knee had its natural size and shape, and the only 
symptom was that, when the leg vas extended on the thigh a 
grating and crackling could be felt and heard distinctly. This 
was especially observed on walking up stairs. 



OF THE JOINTS. 191 

Such cases are not very uncommon, and they occur espe- 
cially among young women, who have a disposition to hys- 
teria. As far as I know they never have any unfavourable 
termination. 

5. There is a class of cases, of no unfrequent occurrence, in 
which the patient suffers considerable distress, in consequence 
of pain referred to some of the larger articulations, and which 
often occasion no small degree of anxiety and alarm to the pa- 
tient's friends, although there never arise any ultimate bad con- 
sequences. The cases to which I allude occur chiefly among 
hysterical females, but sometimes in the male sex. The disease 
appears to depend on a morbid condition of the nerves, and may 
be regarded as a local hysterical affection. At first there is 
pain referred to the hip or knee, or some other joint without, 
any evident tumefaction; the pain soon becomes very severe, 
and, by degrees a puffy swelling takes place, in consequence 
either of a determination of blood to the part, or of some degree 
of serous effusion into the cells of the cellular texture. The 
swelling is diffused, and in most instances, trifling; but it varies 
in degree: and 1 have known, where the pain has been referred 
to the hip, the whole of the limb to be visibly enlarged from 
the crista of the ilium to the knee. There is always exceeding 
tenderness; connected with which, however, we may observe 
this remarkable circumstance, that gently touching or pinching 
the integuments, in such a way as that the pressure cannot affect 
the deep-seated parts, will often be productive of much more 
pain than the handling the limb in a more rude and careless 
manner. In one instance, where there was this nervous affec- 
tion of the knee, immediately below the joint there was an ac- 
tual loss of the natural sensibility; the numbness occupying the 
space of about two or three inches in the middle of the leg. 
In these, as in all other hysterical complaints, the symptoms 
appear to be kept up and aggravated by being made the subject 
of constant attention and anxiety. 

No general rules can be laid down for the treatment of cases 
of this description. The patient sometimes, when the pain is 
most severe, derives benefit from the use of the following em- 
brocation, applied tepid : — 

r<. Spiritus Rosmarini, giss. 
MisturaB Camphorae, gviss. M. 
Fiat Embrocatio. 



192 ON SOME OTHER DISEASES 

Or the following liniment: — 

$t. Linimenti Camphorse Compositi, giv. 
Extracti Belladonna?, gij. 
Fiat Linimentum. 

Sometimes the symptoms have abated under the use of active 
purgatives; or of valerian combined with bark or ammonia; or 
of injections of asafoetida. Where the menstruation is irregular, 
we may suppose it to be of the first importance that we should 
endeavour to restore this function to its healthy condition; and 
if it be deficient, steel may be exhibited with advantage; or if 
it be excessive, the mineral acids, combined with sulphate of 
magnesia, may be administered instead. In a great number of 
cases, in which the symptoms, which have been just described, 
exist in combination with a feeble circulation, cold hands and 
feet, and almost complete w T ant of appetite, the following com- 
bination of medicines will be found to be very useful: — 

5<. Infusi. Quassise, gss. 

Tincturse ferri ammoniati, gss. 

Ammonise carbonatis, gr. vj. 

Syrupi aurantii, gj. 

Aquae destillatse, gvij. 

Fiat haustus bis vel ter quotidie sumendus. 

But none of these remedies will do for the patient what may- 
be accomplished by other means. Her attention should be as 
much as possible withdrawn from the subject of her complaints, 
and directed to other objects. She should be encouraged to 
take exercise out of doors, especially on horseback; to rise 
early, so that only a moderate number of hours may be passed 
in bed; to live in a cheerful society, and if she has abandoned 
them (which has too frequently happened,) to resume, in all 
respects, the habits of a healthy person. 

In general, it is not difficult to distinguish the cases which 
I have just described from those of more serious disease. 
Careless surgeons, however, frequently fail in their diagnosis; 
and even surgeons of experience do so in some instances. I do 
not hesitate to say, that a large proportion of young ladies, who 
have heretofore been supposed to labour under disease of the hip 
joint, and the great majority of those who have been treated as 
suffering from caries of the spine, have, in reality, been affected 
with these local hysterical symptoms, and nothing more. Ex- 



OF THE JOINTS. 19$ 

cept where there is a question concerning life and death, no 
error in surgical practice can be more dangerous than this; as 
it may lead to a patient being confined to her couch, almost in 
solitude, for months, or even for years, who ought to be taking 
exercise, and breathing the fresh air, and partaking of the 
amusements, and enjoying the society, of those of her own age. 

6. We have abundant opportunities of observing that the 
joints of different individuals are endowed with different de- 
grees of mobility. This is often very evident in the articula- 
tions of the fingers with the metacarpal bones. We see one 
person whose fingers admit of being extended so as to be in a 
line with the bones by which they are supported, but of no 
farther motion in this direction; and we see another in whom 
they are capable of being bent backwards, so that the nails may 
be brought almost in contact with the back of the hand. 1 sup- 
pose that this difference is to be attributed chiefly to the state 
of the ligaments, by which the bones are held together; and a 
corresponding looseness of the ligaments, but existing to a still 
greater extent, will explain the singular liability to dislocation 
which may be observed in some individuals. A gentleman 
consulted me in the year 1S20, who had met with the accident 
of dislocating the patella four times in the right, and once in 
the left knee. The right shoulder had been twice completely 
dislocated, and once there had been a subluxation of the same 
joint. The joint of the left thumb, with the os trapezium, had 
been dislocated several times. In every instance the disloca- 
tion had been reduced with the greatest facility, and generally 
without surgical assistance. The patient, at he time of my 
seeing him, was not more than twenty-three or twenty-four 
years of age, and was in perfect health; except that he was 
subject to occasional severe headaches, apparently connected 
with the state of his digestive organs. No peculiarity could be 
observed in the form and structure of his joints. His muscles 
were strong, and he was capable of considerable muscular exer- 
tion; he was accustomed to a good deal of walking exercise, 
but had not been particularly exposed to the ordinary mecha- 
nical causes of dislocation. 

CASE LXXVII1. 

7. A lady, in the year 1808, first observed a swelling in the 
upper part of one knee, which was unattended by pain, and 

17* 



194 ON SOME OTHER DISEASES 

which increased slowly, but uniformly. In the course of three 
years it had attained so inconvenient a magnitude, that she was 
induced to consent to the removal of the limb. Mr. Thomas, 
under whose care the patient was, performed the operation, 
and allowed me afterwards to examine the amputated joint. 

The tumour occupied the upper part of the knee, beginning 
at the edge of the cartilaginous surface, and extending about 
three or four inches up the lower part of the thigh. It was 
interposed between the muscles and the bone .of the thigh, so 
that the former were seen expanded over it. It was of a gray- 
ish-white colour; composed of fibres of a gristly semi-transpa- 
rent substance, with osseous matter intermixed with it, and 
about two inches in thickness on each side of the femur. At 
the upper part it was seen distinctly originating in the perios- 
teum; at the lower part, the periosteum could not be traced, 
and the structure of the bone was continued into that of the 
tumour. The cartilages and ligaments of the joint were free 
from disease. On the external surface of the synovial mem- 
brane, unconnected with the diseased structure above, there 
were three or four flattened bodies; each of about the size of a 
kidney bean, of a white colour, and of a texture somewhat 
softer than that of cartilage. The synovial membrane itself 
was free from disease. 

There can be no doubt that, in this case, the original disease 
was the osteo-sarcomatous tumour, originating in the periosteum 
of the femur. The circumstance of the other tumours being 
found connected with the synovial membrane, although the in- 
termediate parts were, to all appearance, in a healthy state, is 
remarkable; but something corresponding to this may be ob- 
served in other diseases. For example, when the gland of the 
breast is affected with scirrhus, it is not unusual to find small 
tubercles of a similar structure in the skin near it, at various 
distances from each other, although the intermediate adipose 
substance, as well as the portions of skin between the tubercles 
themselves, exhibit no marks of disease. 

I met with another case, in which the patient appeared to 
labour under an enormous tumour of the hip. It was ascer- 
tained, by dissection, that the hip itself was free from disease, 
and that the enlargement was formed by an osteo-sarcomatous 
growth from the periosteum of the upper extremity of the 



OF THE JOINTS. * 195 

femur. Two other cases have come under my observation^ ap- 
parently similar to that just mentioned, but in which I had not 
the opportunity of examining the parts by dissection. 

8. The following remarkable case seems worthy of being re- 
corded, as it is one of those which might, by a superficial ob- 
server, be mistaken for caries of spine. It confirms a remark 
which I have made formerly, namely, that disease affecting the 
cervical portion of the spinal chord produces paralysis of the 
upper extremities, in the first instance, and of the lower extre- 
mities afterwards. 

CASE LXXIX. 

A young man about twenty-one years of age, in January ,, 
1829, after leading a very irregular life, and especially after 
having been much exposed to damp and cold, was seized with 
a violent pain in the neck, followed by considerable swelling. 
The swelling was situated chiefly on the right side, extending 
from the head to the shoulder. The patient paid little attention 
to his complaints; living as usual with respect to both diet and 
exercise; but, in spite of this neglect, in a short time the pain 
and swelling, in a great degree, but never wholly, subsided. 

In the beginning of the following April, the upper extremity 
of the right side became affected with paralysis. Afterwards 
the opposite limb became, to a great extent, paralytic also. In 
this state he remained, no active remedies having been adopted 
for his relief, until he came under my care, in the beginning of 
June. 

At this time he complained of some degree of pain in the back 
of the head and neck: and he found it difficult to move the 
head from one side to the other. An enlargement and indura- 
tion of the soft parts of the neck was still perceptible in the 
situation of the original swelling. There was complete paralysis 
of the muscles of the right arm, forearm, and hand : those of the 
opposite limb were also paralytic, but some of them were still 
capable of acting feebly, so that he could take hold of the right 
hand with the left, and move it from one position to another. 
The muscles of the lower limbs were feeble, but were capable, 
nevertheless, of supporting the body in the erect posture. 

The bowels were very torpid, and the evacuation of a dark 
colour, a good deal resembling tar in appearance. 



196 ON SOME OTHER DISEASES 

The urine was slightly alkaline, but voided without diffi- 
culty. 

Leeches were applied to the neck, and afterwards a seton 
was introduced. Mercury was given so .as slightly to affect 
the gums. No amendment, however, followed the use of these 
remedies. The lower limbs became paralytic; and on the 19th 
of June the patient died, having been for a short time previously 
in a state of coma. 

On examining the body after death, the ventricles of the brain 
were found to contain about two ounces of watery fluid. The 
brain itself was of an unusually soft consistence. 

The cervical portion of the spinal chord was also softer than 
natural. 

A quantity of soft solid substance, of a gray colour, apparently 
lymph, which had become organized, was found situated be- 
tween the dura mater, and the bodies of the vertebrae, occupying 
the whole of the anterior and some of the posterior part of the 
vertebral canal, and extending from the occiput downwards, as 
low as the fourth cervical vertebra. 

A substance similar to that which was found on the inside of 
the vertebral canal was also found lying on the fore part of the 
bodies of the cervical vertebrae, extending over the oblique and 
transverse processes, and communicating with the internal mass 
by processes extending through the spaces in which the nerves 
are situated, and surrounding the nerves themselves. The ex- 
ternal mass was much larger than the internal, being not only 
thicker, but extending lower down in the neck. In some parts 
it was not less than an inch in thickness: in other parts thinner, 
and, altogether, it was of a very irregular shape. 

9. The following case seems not unworthy of being recorded, 
as it illustrates the changes which are produced in the joints, 
where the patient has been liable to severe attacks of gout for 
a long series of years. 

CASE LXXX. 

An old lady who had suffered in an unusual degree from gout 
for a great part of her life, was supposed at last to labour un- 
der an organic disease of the stomach. She died on the 20th 
of December, 1812, and I was requested to examine the body. 

Externally it was observed that several joints of the fingers 



OF THE JOINTS. 197 

were anchylosed, and the fingers variously distorted. The 
middle finger of the left hand was shorter than the rest, and 
the skin over it was loose. The bone of the second phalanx 
appeared to have been nearly absorbed, so that there were 
scarcely any remains of it; there being only a small quantity 
of soft substance in its place. The right wrist and elbow were 
anchylosed, as were also several of the joints of the toes. The 
knees admitted of incomplete flexion and extension; and the 
motion of the joints was attended with a grating sensation. 

In various parts of the body there were orifices in the skin 
communicating with membranous cysts, situated in the adipose 
substance, and discharging a chalky fluid. 

On dissection it was ascertained that the pleura puhnonalis 
and pleura costalis were universally adhering. The peritoneal 
surfaces of the stomach, spleen, liver, and gall bladder adhered 
universally to each other and to the contiguous parts. There 
were no other preternatural appearances in the thorax and ab- 
domen. 

There were no remains of the cartilages in the left knee. 
The corresponding parts of the patella and condyles of the 
femur had the appearance of having been worn into grooves 
and ridges, from their friction on each other: presenting, how- 
ever, a compact surface, the cancellous structure not being ex- 
posed, as would have been the case if friction had been carried 
to the same extent in the dead body. A thiri layer of white 
chalky matter had been deposited on the bones, where the 
cartilages had disappeared, in several places. On the margin 
of the articulating surfaces were several small exostoses. The 
ligaments and synovial membrane were little altered from their 
natural state; with this exception, that the thin layer of the 
latter, which is extended over the cartilages, had disappeared 
with the cartilages themselves. In the right wrist the first row 
of the carpal bones were anchylosed to each other and to the 
radius. 

The other joints were not examined. 



The peculiar kind of absorption of the cartilages, which had 
taken place in this case, and which I have observed in other 
cases of long-standing gout, occurs also in some of those cases 
of chronic rheumatic inflammation of the synovial membranes, 






19S ON SOME OTHER DISEASES 

which are often distinguished by the appellation of rheumatic 
gout, and of which I have given some account in the concluding 
part of the second section of the first chapter of this work. 

In these cases the process by which absorption is effected is 
manifestly different from ulceration, and is altogether very 
remarkable. The cartilages disappear, so that the bones are 
exposed: but the latter present nothing corresponding to the 
appearance of a carious surface. They bear evident marks of 
having been subjected to the influence of friction; but the con- 
sequences of friction on the living are entirely different from 
those of friction on the dead bone. There is no exposure of 
the cancellous structure : a process of repair goes on simulta- 
neously with that of destruction, and the result is the deposite 
of a hard and compact layer of bone over the cancellous struc- 
ture, which must have been exposed otherwise. 

10. Mr. Mayo has published a history of some cases, in 
which the ulceration of the articular cartilages took place un- 
der peculiar circumstances, having the character of being an 
acute disease instead of a chronic affection, as in other instances. 
Since Mr. Mayo's paper on this subject was published in the 
Medico-Chirurgical Transactions, some cases apparently of the 
same kind have fallen under my own observation. They are 
recorded in a former part of this volume. 

11. I may take this opportunity of noticing a circumstance, 
which is of some importance as connected with the diagnosis 
of disease in the hip joint. 

It occasionally happens that the two lower extremities are 
not of precisely the same length; and this may be the result of 
original formation, the femur and tibia of one side being re- 
spectively longer than those of the other side. If the whole 
of this difference amounts, as it sometimes does, to an inch, or 
an inch and a half, the individual is observed to limp in walk- 
ing, and the great trochanter belonging to the longer limb is 
higher and more prominent than that of the other; and this 
sometimes leads a superficial observer to mistake the case for 
one of diseased hip. 

In some instances, there is a difference in the length of the 
two lower limbs, in consequence of disease. A diseased bone 
for the most part does not keep pace in its growth with the 
other parts of the body; but I have known the reverse of this 
to happen, of which the following is a remarkable instance: — 



OF THE JOINTS. 199 

CASE LXXXI. 

Master M. was brought to me from St. Petersburgh for my 
opinion, in June, 1S32. I saw him in consultation with Dr. 
Lefevre, physician to the British embassy in that metropolis. 

The cicatrices of three or four abscesses were seen in the 
skin on the anterior and upper part of the thigh, and there was 
considerable thickening of the deep-seated soft parts in the 
same situation, there being also a manifest adhesion of them to 
the bone. The appearance of the limb was such as would lead 
to the belief that there was a portion of diseased or dead bone 
of the femur, with probably some new bone formed around it; 
and that this had produced a succession of abscesses of the soft 
parts, as in ordinary cases of necrosis. The history of the 
case seemed to justify this opinion as to the nature of the dis- 
ease. 

Three years and a half ago the little boy had been suddenly 
seized with severe pain, which was referred to the knee, but 
only for a few hours, at the end of which time it shifted its 
place to the upper and anterior part of the thigh. The pain 
continued, and swelling immediately took place. At the end 
of six months an abscess was opened, which, however, soon 
healed. Afterwards a second abscess formed, which w T as fol- 
lowed by others; but all of them had healed without any exfo- 
liation having hitherto taken place. 

There was some degree of stiffness of the hip-joint, but no 
more than might be reasonably attributed to the thickening and 
swelling of the soft parts in the neighbourhood. But the most 
remarkable circumstance in the case was, that the diseased 
thigh-bone, when measured from the anterior superior spinous 
process of the ilium to the patella, was found to be at least an 
inch and a quarter longer than that of the sound limb. The 
measurement was made repeatedly and with the greatest care, 
so that there could be no mistake respecting it. There was no 
perceptible difference in the length of the bones of the two legs. 

In consequence of one limb being thus longer than the other, 
when the patient stood erect, with the soles of his feet planted 
on the ground, the great trochanter on the side of the disease 
appeared to project unnaturally, and this occasioned a manifest 
alteration in the form of the nates, somewhat corresponding to 
what is observed in the less advanced stage of disease of the 



200 ON INFLAMMATION 

hip-joint. That this appearance of the nates was to be attri- 
buted solely to the difference in the length of the two limbs, was 
proved by this circumstance, that it was at once removed by 
placing a book an inch and a quarter in thickness under the 
foot of the sound limb, so as to raise that side of the pelvis to 
the same level with the other. 



CHAPTER X. 

ON INFLAMMATION OF THE BURSiE MUCOSA.* 



SECTION I. 

HISTORY AND SYMPTOMS OF THIS DISEASE. 

Inflammation of the hursae mucosae is marked by nearly 
the same characters, and (allowance being made for the differ- 
ence of the parts with which they are connected) produces 
nearly the same results as inflammation of the synovial mem- 
branes of the joints. In the greater number of instances, it 
occasions an increased secretion of synovia. In other cases, 
the bursa is distended by a somewhat turbid serum, with por- 
tions of coagulated lymph floating in it. . Occasionally it ter- 
minates in the formation of abscess. Sometimes the membrane 
of the bursa becomes thickened, and converted into a gristly 
substance. I have seen it at least half an inch in thickness, 
with a small cellular cavity in the centre containing synovia. 
At other times, although the inflammation has continued for a 
very long period, the membrane of the bursa retains nearly its 
original structure. « 

Inflammation of the bursas mucosae may be the consequence 
of pressure, or of other local injury. It may arise from the 

* I include under this head the membranes forming the sheaths of tendons, 
which have the same structure, answer a similar purpose, and cannot with 
propriety be distinguished from other bursa. I adopt the term bursa mucosa, 
because it has been in general use, although it ill expresses the functions of 
the organs to which it is applied. 



OF THE BURS.2E MUCOSA. ' 201 

too great use of mercury, from rheumatism, or from some other 
constitutional affection ; and, in such cases, it is frequently com- 
bined with inflammation of the synovial membranes of the joints. 
Sometimes it has the form of an acute, but more frequently it 
has that of a chronic inflammation. The inflamed bursa forms 
a tumour, more or less distinct, according to its situation; more 
or less painful, according to the character of the inflammation. 
If the bursa be superficial, the fluctuation of the fluid within it 
is, in the first instance, very perceptible; and, under these cir- 
cumstances, if the inflammation be considerable, it extends to 
the surrounding parts, and occasions a redness of the skin. 
When the disease has existed for some time, it generally hap- 
pens that the fluid is less distinctly to be felt on account of the 
membrane having become thickened; and, occasionally, this al- 
teration takes place to such an extent, that the tumour exhibits 
all the characters of a hard solid substance, of which the fluid 
contents are imperceptible. 

When the inflammation is of long standing, it is not unusual 
to find floating in the fluid of the bursa a number of loose bodies, 
of a flattened oval form, of a light brown colour, with smooth 
surfaces, resembling small melon seeds in appearance. There 
seems to be no doubt that these .loose bodies have their origin 
in the coagulated lymph which was effused in the early stage 
of the disease; and I have had opportunities, by the examina- 
tion of several cases, to trace the steps of their gradual forma- 
tion. At first the coagulated lymph forms irregular masses of 
no determined shape, which afterwards, by the motion and 
pressure of the contiguous parts, are broken down into smaller 
portions. These, by degrees, become of a regular form, and 
assume a firmer consistence: and at last they terminate in the 
flat oval bodies, which have been just described. 

When inflammation of a bursa mucosa ends in suppuration, 
the abscess sometimes makes its way directly to the surface of 
the skin, and bursts externally: but I suspect that, in other 
cases, the .matter, in the first instance, escapes into the sur- 
rounding cellular membrane, and then it is liable to be con- 
founded with those abscesses, which originate in this texture. 
The following circumstances seem to warrant this opinion. 
There is no bursa more liable to be inflamed than that between 
the patella and the skin; and inflammation of it not unfre- 
18 



202 ON INFLAMMATION 

qnently terminates in suppuration, as I have ascertained to be 
the case, both by the discharge of pus, when the tumour has 
been punctured, and by dissection after death. It is very com- 
mon to find a large abscess on the anterior part of the knee, 
which the patient describes as having commenced over the 
centre of the patella in the situation of this bursa. The abscess 
has a somewhat peculiar character. It raises the skin from the 
patella, so that the latter cannot be felt, and from this point, 
as from a centre, it extends itself between the skin and the 
fascia, equally in every direction, covering the whole of the 
anterior part of the knee. A careless observer, judging from 
the general form of the tumour, and the fluctuation of fluid, 
without noticing the greater redness of the skin, and the cir- 
cumstance of the fluid being over, instead of under, the patella, 
might mistake the case for one of inflammation of the synovial 
membrane of the joint itself. Such an abscess must be sup^ 
posed to commence either in the bursa above mentioned, or in 
the cellular texture. The original situation of the disease cor- 
responds to that of the bursa: there appears to be no reason 
why an abscess of the cellular texture should occur in this pre- 
cise spot, more frequently than elsewhere; and hence, it is rea- 
sonable to conclude, that the .bursa is the part in which the ab- 
scess begins. It is not improbable that many other abscesses 
of the extremities may have a similar origin. The tumour 
which occurs in the inside of the ball of the great toe, and 
which is one of those to which the name of bunion has been 
applied, occasionally suppurates; and I have found, on dissec- 
tion, that this is formed by an inflammation of the bursa, which 
is here situated. 

It frequently happens, after the inflammation has entirely 
subsided, that the disposition to secrete a preternatural quantity 
of fluid still remains, and that a dropsy of the bursa is the con- 
sequence; in like manner as hydrocele takes place, in some 
cases, as a consequence of inflammation of the tunica vaginalis 
of the testicle. Such tumours are very commonly met with in 
the neighbourhood of the wrist, and are sometimes confounded 
with ganglions. The enlarged bursa on the anterior part of 
the wrist has somewhat peculiar characters: it is bound down 
in the centre by the strong annular ligament, which binds 
down the flexor tendons; and it is prominent above and below, 



OF THE BURSJE MUCOSA. 203 

where the superjacent parts afford a smaller degree of resistance. 
Pressure made on the upper part of the tumour causes the fluid 
to pass altogether into the palm of the hand, and in like man- 
ner, pressure on the lower part of it causes it to ascend into the 
forearm. 



SECTION II. 

ON THE TREATMENT. 

In the first instance, leeches and cold lotions, and afterwards 
blisters, or stimulating liniments, may be employed with ad- 
vantage; and in particular cases these may be combined with 
the use of the Colchicum, or such constitutional remedies as 
their peculiar circumstances seem to indicate. Under this 
treatment the inflammation of the bursa may be relieved with- 
out difficulty; and in the early stage of the disease, the fluid 
which has been effused will become absorbed. 

But where the disease has been long established, the preter- 
natural secretion of fluid will often continue after the inflam- 
mation has entirely subsided. Under these circumstances a 
blister may be applied, and kept open with the savine cerate, 
the part being at the same time supported by a splint or ban- 
dages, so as to limit its motion, or rather, so as to keep it in a 
state of absolute immobility. In many cases the loose bodies, 
which have been described in the last section, are found in the 
cavity of the bursa; and these may in themselves be sufficient 
to keep up the formation of fluid. Under these circumstances, 
the first step towards a cure is to puncture the bursa, so as to 
allow these loose bodies to escape. 

I have observed where the puncture of the tumour is followed 
by suppuration, and the whole cavity of the bursa is thus con- 
verted into an abscess, that, after the suppuration has ceased, 
no farther collection of fluid, in general, takes place, so that 
there is a permanent cure of the disease. Hence, I have some- 
times been induced, after using the lancet, to bring on suppu- 
ration by artificial means. This may be effected by introducing 
a seton or tent into the wound, or by making a free opening 
into the bursa, and dressing the cavity of it with lint. Even 



204 ON INFLAMMATION 

where the bursa forms the sheath of one or more tendons, this 
method may be employed with safety; provided that the bursa 
has no communication with the cavity of the neighbouring 
joint, and that care is taken to prevent the lodgment of pus, 
and the consequent formation of sinuses. 

We must, however, proceed with caution where the bursa is 
dilated to a considerable size. Inflammation and suppuration 
of a large bursa sometimes disturbs the constitution in so great 
a degree, that it may be doubtful whether it would be prudent, 
in this instance, to do more than simply puncture the tumour, 
keeping the patient in a state of perfect quietude afterwards. 
A large' swelling; formed by a cyst distended w T ith serum only, 
or with serum and masses of coagulated lymph floating in it, 
occasionally is met with over the inferior angle of the scapula; 
occupying the situation of the large bursa mucosa, which is in- 
terposed at this part between the scapula and the lalissimus dorsi 
muscle, but of which I am inclined to believe that it is more 
frequently formed by one* of the bursse of the shoulder, dis- 
tended with fluid, and protruding from underneath the muscles 
by which that joint is surrounded. I had an opportunity of 
seeing a tumour of this description, which had attained a mag- 
nitude not much less than that of a man's head. I understood 
that the cyst was afterwards punctured, and a seton passed 
through its cavity, and that so much disturbance of the general 
system ensued as to occasion death. I have seen another case, 
in which death took place in a short time after such a tumour 
was punctured: but here the patient was otherwise in bad 
health, and that strict attention was not paid to his being kept 
in a state of quietude after the operation, which the circum- 
stances seem to have required. I shall give an account of a 
more fortunate case of the same kind hereafter. 

When the coats of the bursa have become much thickened, 
I am not aware that there is any method, by which they can 
be restored to their natural condition. If the diseased bursa be 
situated superficially, it may be removed with as much facility 
as an encysted tumour. I have never, indeed, performed this 
operation myself, nor have I heard of it being done by others, 
except on the bursa, which is situated between the patella and 
the skin; but there can be no doubt that there are some other 
superficial bursae to which the operation would be equally ap~ 



OF THE BURS.2E MUCOSJE. 205 

plicable if occasion called for it. On the other hand, where the 
bursa envelops tendons, or where it is deep-seated, the opera- 
tion must be impracticable; and where the bursa communicates 
with the cavity of a joint, if practicable, it must be improper. 

In those cases, where the bursa over the patella has been ex- 
tirpated, I do not know that the patient has afterwards suffered 
any inconvenience from the want of it; and, in fact, there is 
sufficient evidence that a new bursa is ultimately formed in the 
place of that which had been taken away. A synovial mem- 
brane is of simple structure. It may be resolved by maceration 
into cellular texture; and instances are not wanting of new sy- 
novial membranes being formed where none before existed. 
Such is the case in an artificial joint after an ununited fracture. 
In a young lady, who kad attained the age of ten or twelve 
years, labouring under the inconvenience of a club foot, a large 
bursa was distinctly to be felt on that part of the instep which 
came in contact with the ground in walking: and in another 
young lady, who had apparently recovered of a caries of the 
spine, attended with a considerable angular curvature, a bursa 
appeared to have been formed between the projecting spinous 
process and the skin. 



SECTION III. 

CASES OP THIS DISEASE. 

CASE LXXXII. 

Mary Newnham, twenty-two years of age, was admitted 
into St. George's Hospital, having the bursa over the right pa- 
tella enlarged to the size of a small orange. It contained fluid, 
and the membrane of the bursa appeared to be very little thick- 
ened. At this time she experienced no pain, and there was no 
inconvenience, except what arose from the bulk of the tumour. 

Blisters having been applied, and other methods having been | 
employed, with a view to promote the absorption of fluid, with- 
out success, I made a puncture with a lancet, and more than an 
ounce of serous fluid escaped. I then introduced the blunt end 

18* 



206 ON INFLAMMATION 

of a probe, and irritated the inner surface of the bursa; in con- 
sequence of which, on the following day, there was some de- 
gree of pain and swelling, with a slight degree of symptomatic 
fever. On the fourth day after the operation, on removing the 
dressings, about half an ounce of pus was discharged. The sup- 
puration continued, but the quantity of pus daily diminished, 
and, at the end of three weeks, the wound was healed, and the 
tumour had wholly disappeared. 

CASE LXXXIII. 

Mrs. T., between twenty and thirty years of age, in the 
middle of March, 1818, first observed a tumour situated over 
the inferior angle of one scapula, and attended with a trifling 
degree of pain and tenderness. In thfc course of a week, the 
tumour had attained its greatest magnitude, and then remained 
stationary- In the following April, when she came under my 
care, the tumour was of the size of a large cocoa-nut; of an oval 
shape; distinctly circumscribed; occupying the place of the 
large bursa mucosa, which is situated between the latissimns 
dorsi muscle and the inferior angle of the scapula. 

On the 22d of May, the tumour being nearly in the same 
condition, I made a puncture with an abscess lancet, and about 
a pint of turbid serum was evacuated, with some irregularly 
shaped masses of coagulated lymph floating in it. Adhesive 
plaster was placed over the wound, and secured by a compress 
and bandage: and she was desired to remain perfectly quiet in 
bed. The wound did not heal by the first intention; and, on 
removing the dressing at the end of four days, a considerable 
quantity of pus escaped. The discharge of pus continued, but 
the quantity daily diminished; no untoward symptoms took 
place, but nearly three months elapsed before the suppuration 
had entirely ceased, and the wound had healed. At this time 
there were no rernains of the tumour, and she was in all re- 
spects well. 

CASE LXXXIV. 

A. B., a middle-aged woman, became a patient of St. George's 
Hospital, under Mr. Keate, on account of a tumour on the back 
part of the wrist, of the size of a double walnut, containing 
fluid; and which had beeu the consequence of inflammation of 
the bursa mucosa, which envelops the extensor tendons of the 



OF THE BURS^ MUCOSAE. 207 

fingers. At the time of her coming to the hospital the inflam- 
mation had entirely subsided, and the tumour occasioned no 
inconvenience, except what might be attributed to its bulk. 
After having employed various local remedies without any re- 
duction of the swelling, a puncture was made, and a considera- 
ble quantity of serous fluid was evacuated. In a short time, 
however, the fluid was again collected in as large a quantity as 
before. Afterwards Mr. Keate made a longitudinal incision 
in the skin over the tumour, and dissected out as much as pos- 
sible of the bursa, Ieaving'only that part of it which enveloped 
the tendons. The wound suppurated, and healed gradually; 
and, at first, it was supposed that the operation had produced a 
cure. But in a few weeks after the wound had cicatrised, the 
tumour re-appeared, having the same character as before, but 
being of not more than one half of its former size: and when I 
last saw the patient, it continued in the same state. 

CASE LXXXV. 

Ruth Target was admitted into St. George's Hospital, in 
August, 1S09, on account of a hard, and apparently solid, tu- 
mour, of the size of a small orange, situated between the pa- 
tella and the skin, and perfectly moveable on the parts below. 

Having made a longitudinal incision of the integuments, I 
removed the tumour with perfect facility. A slight degree of 
symptomatic fever followed the operation, which, however, 
speedily subsided, and, at the end of a month, she was dis- 
charged as cured, suffering no inconvenience except a very tri- 
fling sense of stiffness when she walked. 

On examining the tumour, after its removal, it was found to 
be formed by the bursa, which is situated over the patella; the 
parietes of which had become more than half an inch in thick- 
ness, and of a ligamentous texture; while the interior retained 
its natural cellular structure, and was filled with a serous fluid. 

I have since performed a similar operation on several patients. 
In each case, after the wound was healed, there was at first 
considerable stiffness of the knee, in consequence of the cicatrix 
having formed a close attachment to the anterior surface of the 
patella. Where, however, I had the opportunity of seeing the 
patient afterwards, I always found that this inconvenience had 
been of short duration, and that there was every reason to be- 



208 ON ULCERATION 

lieve that the bursa had been regenerated. The following case 
is not without interest, proving as it does, beyond the possi- 
bility of doubt, that such regeneration actually takes place. 

CASE LXXXVI. 

Mary Buddy, seventeen years of age, was a patient in St. 
George's Hospital, in the beginning of the year 1828, on account 
of a tumour formed by an enlargement of the bursa between 
the patella and the skin. The tumour was removed entire by 
the late Mr. Rose. 

About the beginning of November, 1828, another tumour 
presented itself in the situation of that, which had been taken 
away. This tumour gradually increased in size; and, when she 
was re-admitted into the hospital on the 14th of January, 1829, 
it had all the character of an enlarged bursa, occupying the ex- 
act place of that which had existed formerly. 

January 21st. I made a free incision into the tumour with 
a lancet. There was a cavity in its centre, from which lymph 
and serum escaped. The surface of it thus exposed was dressed 
with dry lint and a poultice over it. It soon became covered 
with granulations; and on the 4th of February the patient left 
the hospital cured. 



NOTE 

ON ULCERATION OF THE ARTICULAR CARTILAGES. 

Among the cases w T hich have been recorded in the foregoing 
pages, there are several in which the cartilages of a joint were 
found to have been absorbed on the surface towards the articular 
cavity; while the layer, next the bone, retained its natural ad- 
hesion, and was in other respects unaltered. I have always 
regarded this partial removal of the cartilage as not to be ex- 
plained, except on the supposition of its having been acted on 
by its own vessels. And, in the beginning of the fourth chap- 
ter, I have given my reasons for believing that this circumstance 
is by no means remarkable, or contrary to what might, a priori, 
have been expected. 

My friend Mr. Key, in an interesting paper, which he has 
lately published in the Medico-Chirurgical Transactions, has 



OF THE ARTICULAR CARTILAGES. 209 

related the history of a case, in which a similar appearance of 
the cartilage was connected with an inflamed state of the syno- 
vial membrane, processes or elongations of which were seen 
lying in contact with" the articulating surfaces; and from this 
and some other circumstances, he has been led to infer, that this 
kind of absorption of the cartilage is to be attributed, not to 
any changes originating in the cartilage itself, but to the action 
of the vessels of the synovial membrane; and farther, that when 
inflammation of the last mentioned structure is followed by ul- 
ceration of the cartilage, the ulceration is accomplished in the 
same manner; the vessels of the cartilage being, in fact, unequal 
to such a process of destruction. 

I have had no opportunity of examining the preparation from 
which the drawing annexed to Mr. Key's paper has been taken; 
and I cannot, therefore, venture to contradict the opinion which 
he has expressed respecting this particular case. If it be correct, 
it establishes a new fact in pathology; as I am not aware that 
there is any instance, in other parts of the body, of the ulcera- 
tion or absorption of one living texture being affected by the 
action of the vessels of another, there being no continuity of 
substance between them. 

The perusal of Mr. Key's paper has, however, induced me to 
renew my inquiries on the subject; and, in doing so, I have 
found what appears to me to be abundant and satisfactory evi- 
dence that the explanation, which he has offered, does not ad- 
mit of a general application, and that the absorption of the car- 
tilage commencing on the surface towards the cavity of a joint, 
may take place under such circumstances, that it cannot be sup- 
posed to be the result of any other agency than that of the ves- 
sels of the cartilage itself. The following facts are only a part 
of those which might be adduced if it were necessary, in con- 
firmation of what has been just stated. 

1. At page 65, of this volume, I have mentioned the case 
of a boy in whom this partial absorption of the cartilages of 
the knee had taken place. In some parts the cartilage had 
altogether disappeared; in other parts, it had been absorbed on 
the surface towards the cavity of the joint, while the layer, 
next the bone, remained entire; thus presenting the appearance 
*of grooves, as if a portion of its substance had been removed 
by a chisel. Now, according to Mr. Key's hypothesis, the 



210 ON ULCERATION 

absorption of the cartilage, in this case, ought to have been 
produced by villous processes of the synovial membrane pro- 
jecting into the cavity of the joint, and lying in contact with the 
articulating surfaces. But no such villous processes existed, 
nor is any thing said in my manuscript notes of the synovial 
membrane having been even inflamed. Indeed, if it were in- 
flamed at all, it must have been so only to a very small extent, 
as it is expressly stated, that there was no effusion either of pus 
or synovia, into the cavity of the joint. It is to be presumed 
that, if the absorption of the cartilage had been effected through 
the agency of the synovial membrane, it would have begun, 
and would have made the greatest progress, at the part most 
exposed to contact with it, namely, at the margin; and this cor- 
responds with Mr. Key's own observations on the subject. 
But, in examining the condyles of the femur taken from this 
patient, which are preserved in spirits in the museum of St. 
George's Hospital, I find that this is exactly contrary to what 
has really happened. Throughout nearly the whole of its cir- 
cumference, for the breadth of one-third of an inch, the carti- 
lage remains of its natural thickness, and otherwise unaltered; 
while in the centre it has altogether disappeared, and the 
grooved appearance of it is observable in the intermediate 
space.* 

2. In the case of Harper, related* at page 109, the cartilage 
covering the head of the femur had been destroyed by ulcera- 
tion for more than half its extent, so as to expose the cancellous 
structure of bone. The remaining portion of the cartilage was 
thinner than natural ; but this was more observable in some 
parts than in others. With the exception of one spot of 
limited extent, this partial loss of substance had taken place to- 
wards the cavity of the joint, the layer of cartilage next the 
bone being unaltered. The synovial membrane was some- 
what more vascular than usual; but the increased vascularity 
seemed scarcely to amount to inflammation. 

* It is worthy of notice that in this case there was a large abscess of the 
thigh, external to the knee joint. A similar abscess existed in one of the cases 
described by Mr. Mayo in the Medico-Chirurgical Transactions, to which I 
shall have occasion to refer presently. Three other cases have fallen under 
my observation, in which a large abscess, external to a joint, was accompanied t 
with ulceration of the articular cartilages: no suppuration having taken place 
in the joint itself. 



OF THE ARTICULAR CARTILAGES. 211 

3. I have in my possession a drawing made from a knee, 
amputated within the last six or seven years in St. George's 
Hospital, in which the same partial absorption of the cartilage 
covering the head of the tibia and condyles of the femur had 
taken place, producing the appearance of grooves on the sur- 
face towards the cavity of the joint. In this case there are 
manifest indications of the same process having begun in the 
cartilage of the patella, and of that portion of the femur with 
which the patella was in contact, and to which the villous pro- 
cesses of the synovial membrane (of which there are no indi- 
cations in the drawing.) even if they had existed, could not 
easily have penetrated. The condyles of the femur belonging 
to 'this case are preserved in the museum of St. George's Hos- 
pital ; and, on examining them, I find that the absorption of the 
cartilage had been almost wholly confined to the centre of the 
articulating surface; while at the margin, where it must have 
been the most exposed to the contact of the synovial mem- 
brane, scarcely any absorption of it had taken place. 

4. In a paper on the ulceration of the cartilages of joints, 
published by Mr. Mayo in the 11th volume of the Medico- 
Chirurgical Transactions, a case is described, in which, on ex- 
posing the cavity of the join t^i n dissection, " the surfaces of 
the astragalus, tibia, and fibula were found almost wholly 
stripped of their cartilage: what remained of this texture was 
thinned, and that unequally, but seemed in other respects un- 
changed, and adhered firmly to the bone. The same alteration 
was observed in the other joints, which the astragalus concurs 
in forming. The exposed surfaces of bone were healthy." In 
answer to some inquiries which I have lately made, Mr. Mayo 
has informed me, that "the synovial membrane was red and 
thickened where it lined the capsular ligament; but there were 
none of those villous processes projecting into the cavity of the 
joint which Mr. Key has described as the agents by which the 
absorption of- the cartilages is effected." Indeed, whoever 
considers the peculiar form and relative position of the articu- 
lating surfaces of the ankle-joint, will, I conceive, find it diffi- 
cult to understand how those processes, even if they had ex- 
isted, could have extended into the joint, so as to perform the 
office which Mr. Key has assigned to them. If any farther 
proof be required of the synovial membrane not having been 



212 ON ULCERATION 

concerned in the absorption of cartilage, in this particular in- 
stance, it is afforded by the preparation of the astragalus which 
is preserved in the museum of King's College, and which Mr. 
Mayo has allowed me to examine. In the central part of each 
articulating surface the cartilage has become absorbed to a great 
extent, and what remains is reduced to a very thin layer, ad- 
hering as firmly as usual to the bone; but at the margin, close 
to the reflection of the synovial membrane over it, a narrow 
stripe of cartilage is almost every where perceptible; and in 
many placed there are portions of cartilage, of their ordinary 
thickness, and evidently not altered from their natural con- 
dition. 

In speaking of ulceration of the articular cartilages as a con- 
sequence of inflammation of the synovial membrane, I have 
not endeavoured to explain the exact nature of the process by 
which such ulceration is effected, and simply for this reason, 
— that I have not been able completely to satisfy my own mind 
on the subject. There can be no doubt that, in many instances, 
ulceration begins at the margin of the cartilage, where the sy- 
novial membrane is reflected over it from the neighbouring 
bone, or from the intqrarticular ligaments, where such ligaments 
exist; but it may still admit of% question, in what manner the 
ulceration is accomplished: whether it be from the inflamma- 
tion extending directly to the cartilage itself, or to the bone 
first, and the cartilage afterwards;* or whether, according to 
the views entertained by Mr. Key, the latter being altogether 
in a passive state, becomes absorbed by the action of the ves- 
sels of the fringed processes of the synovial membrane, lying 
in contact with it. But there are other cases of inflammation 
of the synovial membrane, in which ulceration begins in the 
centre of the cartilage; so that none of these hypotheses afford 
any reasonable explanation of it. 

* I am led to offer this as one of the explanations which might be given of 
ulceration of the cartilage, induced by inflammation of the synovial membrane, 
in consequence of what was observed in Case I. p. 9, in which the cartilage 
presented no appearance of disease, except that, u at the edge of one of the 
condyles of the femur, it adhered to the bone less firmly than usual." I have 
observed, in some other cases, but especially in those of the scrofulous dis- 
ease, which has its origin in the bones, that a similar want of adhesion of the 
cartilage to the bone is not unfrequently to be noticed where the former is 
about to ulcerate. 



OF THE ARTICULAR CARTILAGES. 213 

It seems not improbable, that in some of those cases, which 
are usually regarded as examples of simple inflammation of 
the synovial membrane, the inflammation may not have been 
confined (even in the first instance) to this individual part, but 
may have begun simultaneously in all the textures of the joint. 
This is in conformity with what is observed to happen occa- 
sionally in the eye, and in other organs; and, under such cir- 
cumstances, it is no more than might be expected, that, as the 
inflammation subsides, the cartilage should ulcerate either in the 
centre, or in some other part of its surface. Nor is this a mere- 
ly speculative opinion: at least, I am much mistaken if it be 
viewed in that light by any one who, after having perused the 
history of the following case, considers what would probably 
have happened if the patient had not died of another disease, 
before there was time for the disease in the joint to have run 
its course. 

A gentleman, about twenty-five years of age, had laboured 
for several years under a disease of the brain, in consequence 
of which he had been in a state of complete helplessness and 
imbecility. In the summer of 1S20, he became indisposed 
otherwise: there was a cluster of enlarged glands in the left 
groin, and a purulent sediment w 7 as deposited by the urine. I 
was now desired to see him in consultation with Dr, Maton, 
who was his ordinary medical attendant. Soon afterwards, it 
was observed that there was a general tumefaction of the left, 
thigh and nates, and the patient complained of pain in certain 
motions of the limb. Under the treatment employed, the tu- 
mefaction subsided: but immediately afterwards a violent attack 
of diarrhoea took place; under which he sunk and died on the 
29th of July. 

On examining the body, we discovered an abscess, which 
seemed to have had its origin in the cellular membrane of the 
pelvis, near the neck of the bladder, which had burst into the 
neighbouring portion of the urethra, and which had also ex- 
tended forwards on the left side, so that it could be traced as 
high as the mass of enlarged glands in the groin. 

The whole of the muscles surrounding the left hip-joint were 
preternaturally soft and vascular, and so altered from their na- 
tural condition that they could be lacerated by the slightest 
force. They also were to a considerable extent detached or 
19 



214 ON ULCERATION 

separated from each other, apparently in consequence of a se- 
rous fluid which had been effused between them, but of which 
nearly the whole had become absorbed. The capsular liga- 
ment and synovial membrane of the joint were of a red colour, 
and unusually vascular: and the cartilages covering the head of 
the femur, and lining the acetabulum, w r ere also red, and of a 
soft consistence, giving to the fingers a sensation somewhat re- 
sembling that which is produced by touching velvet. 

In the scrofulous disease of the joints, which is described in 
the fifth chapter, the first change commonly observed is, that 
the cartilage adheres less firmly than is usual to the bone, so 
that it may be easily separated from it. This is followed by 
absorption of the cartilage, beginning on the surface towards 
the bone. Occasionally red spots are observed in the cartilage, 
which might be supposed to indicate an increased vascularity 
preceding ulceration, and, in two cases (that of Scales, page 
119, and King, page 121,) vessels injected with red blood could 
be distinctly traced extending from the bone into the cartilages 
covering them. A similar appearance has been observed and 
described by Mr. Mayo, and a preparation exhibiting the vas- 
cularity of inflamed cartilage has been preserved by him in the 
Museum of King's College, London. 

The degeneration of the cartilage into a fibrous structure is 
no uncommon circumstance; and I suspect that it is one cause 
of the crackling of the joints, which is not uncommonly met 
with in persons somewhat advanced in life. I have no doubt 
that it often exists where it is never followed by ulceration; 
but I am also well assured that, in many other instances, it pre^ 
cedes, and, in fact, forms, the first stage of this disease; and se- 
veral cases, confirming this observation, are recorded in former 
parts of the present volume. 

There are other cases, in which what I have described as 
primary ulceration of the cartilage is preceded, not by this pe- 
culiar change of structure, but by a chronic inflammatory affec- 
tion of the bone to which the cartilage is attached. I do not 
undertake to explain how these two orders of cases are to be 
distinguished from each other in the living person: and, in fact, 
in the present state of pathological science, it is no more possi- 
ble to do so, than it is to determine whether a node, formed by 
a thickening of the periosteum, has originated in the periosteum 



OP THE ARTICULAR CARTILAGES. 215 

itself, or in the bone which it envelops. Indeed, it is only 
during the very early stage of the disease that this distinction 
can be made, even by the morbid anatomist; as, whatever may 
have been the state of the bone originally, its cancellous struc- 
ture becomes affected with chronic inflammation as soon as ul- 
ceration originating in the cartilage has extended to it. 

Mr. Key has expressed some doubts whether, in the ordinary 
disease of the hip-joint, the cartilage is the part primarily af- 
fected; and seems to regard it rather as the consequence of in- 
flammation of the ligamentum teres. On this, as on other sub- 
jects connected with these inquiries, I do not undertake to do 
more than state the results of my own individual experience; 
and they are as follow: — During a series of years, 1 sought every 
opportunity of examining the morbid appearances of the hip- 
joint, more especially in the early stage of disease, whatever 
the disease might be; and, in the cases which came under my 
observation, I certainly found, in children under the age of pu- 
berty, that the scrofulous disease described in the fifth chapter 
predominated, while, in adults, the disease, for the most part, 
manifestly began either in the cartilage itself, or in the surface 
of the bone beneath. In making this observation, of course I 
do not mean to contradict what I have formerly stated with re- 
spect to the occurrence of ulceration of the cartilages of the hip 
as a consequence of inflammation of the synovial membrane. 
Neither do I mean to assert, that there is no such thing as in- 
flammation of the ligamentum teres preceding ulceration of the 
harder textures: but I am not aware that I have ever met with 
an instance of the kind; nor is it what I should have much ex- 
pected to be the case, considering how little liable the other ar- 
ticular ligaments appear to be to inflammatory affections.* 

* The view which I have taken of the more important diseases which occur 
in the hip-joint derives confirmation from what we see of those diseases of 
the joints between the bodies of the vertebra which terminate in caries of the 
spine. We cannot overlook the correspondence between the diseases of the 
spine and those of the hip; nor how they occur under similar circumstances, 
run nearly the same course, and seem for the most part to depend on the same 
state of constitution. But the joints between the bodies of the vertebrae have 
no synovial membranes: and I do not know that there is the smallest evidence 
in favour of the opinion, that the ligaments of the spine are ever the parts 
primarily affected. I have formerly stated, " that an extensive caries of the 
spine may have its origin, sometimes in an ulceration of the intervertebral 



216 ON ULCERATION, &C. 

Notwithstanding the ingenious arguments advanced by Mr. 
Key, I must acknowledge, that I find no just grounds for the 
opinion, that the articular cartilages are so little liable, as he 
supposes them to be, to become ulcerated from the action of 
their own vessels. They may be regarded as bearing nearly 
the same relation to the synovial membrane which the transpa- 
rent cornea bears to the tunica conjunctiva: yet how rare is it to 
find ulcers of the last-mentioned texture, and how frequent are 
ulcers of the cornea! I am not aware that there is any good rea- 
son to believe that the capability of ulceration is greater in those 
textures which possess much vascularity than it is in others. It 
is true, that tendons do not readily ulcerate; but the same ob- 
servation may be made with respect to the muscles to which 
they are attached, although the latter receive a larger supply of 
blood, and, apparently, have their vital powers more developed 
than almost any other part of the animal system. The cicatrix 
of an ulcer, after a certain time, becomes less vascular than the 
skin by which it is surrounded; yet, it is well known that the 
former is made to ulcerate from causes, which would not pro- 
duce ulceration in the latter; and this circumstance is, indeed, 
usually regarded as a proof of the cicatrix being endowed with 
inferior vital powers to those which belong to parts of original 
formation. But, setting these arguments aside, it may be ob- 
served that, although the articular cartilages in the adult, and 
when free from disease, exhibit no vessels capable of carrying 
red blood, they must, nevertheless, be well supplied with the 
means of growth, and, probably, have greater power of repara- 
tion than any other textures in the body. None are exposed 
in the same degree to the influence of pressure and friction; 
which, however, produce no change in their condition. As 
long as they are thus exercised, they retain their natural thick- 
ness, and all their properties, unimpaired; but, when these 
causes cease to operate, they waste like other organs, which 
are not kept in constant use, and, in the course of time, almost 
wholly disappear. 

cartilages, and, at other times, in a morbid condition of the cancellous struc- 
ture of the bodies of the vertebrae;" and, whoever will be at the pains of seek- 
ing opportunities of studying the pathology of caries of the spine by dissec- 
tions made at an early period of the disease, will, if I am not much mistaken:, 
find abundant reason to confirm the truth of the above observation. 

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Cyclopaedia of Practical Medicine, continued. 



Abdomen, Exploration of the, Dr.. 
Forbes. 

Abortion, Dr. Lee. 

Abscess, Internal, Dr. Tweedie. 

Abstinence, Dr. Marshall Hall. 

Achor, Dr. Todd. 

Acne, Dr. Todd. 

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Age, Dr. Roget. 

Air, Change of. Sir James Clarke. 

Alopecia, Dr. Todd. 

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Anaemia, Dr. Marshall Hall. 

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Angina Pectoris, Dr. Forbes. 

Anodynes, Dr. Whiting. 

Anthelmintics, Dr. A. T. Thomson. 

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Antispasmodics^ Dr. A. T. Thomson. 

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" Pulmonary, Dr. Town- 
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Ascites, Dr. Darwali. 

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" of the New Born, Dr. Dun- 
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Atrophy, Dr. Townsend. 

Auscultation, Dt. Forbes. 

Barbiers, Dr. Scott. 

Bathing, Dr. Forbes. 

Beriberi, Dr. Scott 



CONTENTS OF VOLUME I. 

Blood, Determination of, Dr. Barlow. 
" Morbid States of, Dr. Marshall 

Hall. 
Blood-letting, Dr. Marshall Hall. 
Brain, Inflammation of the, 

Meningitis, Dr. Quain. 
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Bronchial Glands, Diseases of the, 

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Brown. 

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Cirrhosis of the Lung, Dr. Dunglison. 
Climate, Dr. Clark. 
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Coma, Dr. Adair Crawford. 
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Congestion of Blood. Dr. Barlow. 
Constipation, Drs. Hastings and 

Streeten. 



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Convulsions, Dr. Adair Crawford. 

" Infantile. Dr. Locock. 

" Puerperal, Dr. Locock, 

Coryza, Dr. Williams. 
Counter Irritation, Dr. Williams. 
Croup, Dr. Cheyne. 
Cyanosis, Dr Crampton. 
Cystitis, Dr. Cumin. 
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Dunglison . 
Dengue, Dr. Dunglison. . 
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Derivation, Dr. Stokes. 
Diabetes, Dr. Bardsley. 
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Education, Physical, Dr. Bariow, 
Electricity, Dr. Apjohn. 
Elephantiasis, Dr r Joy. 
Emetics, Dr. A. T. Thomson. 
Emmenagogues, Dr. A. T. Thomson* 



CONTENTS OF VOLUME II. 



Emphysema, Dr. R. Townsend. 
" of the Lungs, Dr. R. 

Townsend. 
Empyema, Dr. R. Townsend. 
Endemic diseases, Dr. Hancock. 
Enteritis, Drs. Stokes and Dunglison. 
Ephelis, Dr. Todd. 
Epidemics. Dr. Hancock. 
Epilepsy, Dr. Cheyne. 
FJpistaxis, Dr. Kerr. 
Erethismus Mercurialis, Dr. Burder. 
Erysipelas. Dr. Tweedie. 
Erythema, Dr. Joy. 
Eutrophic.Dr. Dunglison. 
Exanthemata, Dr. Tweedie. 
Expectorants, Dr. A. T. Thomson. 
Expectoration. Dr. Williams. 
Favus, Dr. A. T. Thomson. 
Feigned diseases, Drs. Scott, Forbes 

and Marshall. 
Fever, general doctrine of, Dr. Twee- 
die. 

" Continued, and its modifica- 
tions, Dr. Tweedie. 

" Typhus, Dr. Tweedie. 

" Epidemic Gastric, Dr. Cheyne. 

" Intermittent. Dr. Brown. 

" Remittent. Dr Brown. 

" Malignant Remittent, Dr. Dun- 
glison. 



Fever, Infantile, Dr. Joy. 
" Hectic, Dr Brown. 
" Puerperal. Dr. Lee. 
" Yellow, Dr. Gilkrest. 
Fungus Haematodes, Dr. Kerr. 
Galvanism, Drs. Apjohn and Dungli- 
son. 
Gastritis, Dr. Stokes. 
Gastrodynia, Dr Barlow, 
Gastro-Enteritis, Dr. Stokes. 
Glanders, Dr. Dunglison. 
Glossitis, Dr. Kerr. 
Glottis, Spasm of the, Dr. Joy. 
Gout, Dr. Barlow. 
Haematemesis, Dr. Goldie. 
Haemoptysis, Dr. Law. 
Headache, Dr. Burder. 
Heart, Diseases of the, Dr. Hope. 
" Dilatation of the, Dr. Hope. 
* Displacement of the, Dr. 

Townsend. 
" Fatly and greasy degenera- 
tion of the, Dr. Hope. 
" Hypertrophy of the, Dr. Hope. 
" Malformations of the, Dr. Wil- 
liams. 
" Polypus of the, Dr. Dunglison 
" Rupture of the, Dr. Townsend 
" Diseases of the Valves of the 
Dr. Hope. 



Haemorrhage, Dr. Watson. 
Haemorrhoids, Dr. Burne. 
Hereditary Transmission of Disease-,. 

Dr. Brown. 
Herpes, Dr. A. T. Thomson. 
Hiccup, Dr. Ash. 
Hooping Cough. Dr. Johnson. 
Hydatids, Dr. Kerr.. 
Hydrocephalus, Dr. Joy. 
Hydropericardium, Dr. Darwalh 
Hydrophobia, Dr. Bardsley. 
Hydrothorax. Dr. Darwali. 
Hyperesthesia, Dr. Dunglison. 
Hypertrophy, Dr. Townsend. 
Hypochondriasis, Dr. Pritchard, 
Hysteria, Dr. Conolly. 
Ichthyosis, Dr. Thomson. 
Identity, Dr. Montgomery. 
Impetigo, Dr. A. T. Thomson. 
Impotence, Dr. Beatty. 
Incubus, Dr. Williams. 
Indigestion, Dr. Todd. 
Induration, Dr. Carswell. 
Infanticide, Dr. Arrowsmith. 
Infection, Dr. Brown, 
inflammation, Drs. Adair Crawford 

and Tweedie. 



CONTENTS OF VOLUME III. 



Influenza. Dr. Hancock. 
Insanity. Dr. Pritcharri. 
Intussusception Dr. Dunglison. 
Irritation. Dr. Williams. 
Jaundice. Dr. Burder. 

■ of the Infant, Dr. Dunglison 
Kidney*, diseases of. Dr. Carter. 
Lactation. Dr. Locock. 
Laryngitis, Dr. Cheyne. 

" Chronic. Dr. Dunglison. 

Latent diseases. Dr. Christison. 



Lepra, Dr. Houghton. Medicine, State of in the 19th Cenr 

Leucorrhcea, Dr. Locock. tury, Dr. Alison. 

Lichen, Dr. Houghton. " Practical, Principles of, 

Liver. Diseases of the, Dr. Stokes. Dr. Conolly. 

Liver, Diseases of the, Dr. Venables. Melaena, Dr. Goldie. • 

" Inflammation of the, Dr. Melanosis, Dr. Carswell. 

Stokes. Menorrhagia, Dr. Locock. 

Malaria and Miasma, Dr. Brown. Menstruation, Pathology of, Dr. Lo- 
Medicine, History of, Dr. Bostock. cock. 

" American, before the Re- Miliaria, Dr. Tweedie. 

volution, Dr. J. B. Beck. Milk Sickness. Dr. Dunglison. 



LEA & BLANCHARD'S PUBLICATIONS. 



Cyclopaedia of Practical Medicine, continued. 
CONTENTS OF VOLUME III— Continued. 



Mind, Soundness and Unsoundness 
offtDrs. Pritchard andDunglison. 

Molluscum, Dr. Dunglison. 

Mortification, Dr. Carswell, 

Narcotics, Dr. A. T. Thomson. 

Nauseants, Dr. Dunglison. 

Nephralgia and Nephritis, Dr. Carter. 

Neuralgia, Dr. Elliotson. 

Noli-Me-Tangere or Lupus, Dr. 
Houghton. 

Nyctalopia, Dr Grant. 

Obesity, Dr. Williams. 

CEdema, Dr. Darwall. 

Ophthalmia, Drs. Jacobs and Dungli- 
son. 

Otalgia and Otitis, Dr. Burne. 

Ovaria, Diseases of the, Dr. Lee. 

Palpitation, Drs. Hope andDunglison. 



Pancreas, diseases of the, Dr. Carter. 
Paralysis,Dr. Todd. 
Parotitis, Dr. Kerr. 
Parturients, Dr. Dunglison. 
Pellagra, Dn Kerr. 
Pemphigus, Dr. Corrigan. 
Perforation of the Hollow Viscera, 

Dr. Carswell. 
Pericarditis, Dr. Hope. 
Peritonitis, Drs. Mc Adam and Stokes. 
Phlegmasia Dolens, Dr. Lee. 
Pityriasis, Dr. Cumin. 
Plague, Dr. Brown. 
Plethora, Dr. Barlow. 
Pleurisy, Dr. Law. 
Plica Polonica, Dr. Corrigan. 
Pneumonia, Dr. Williams. 



Pneumothorax, Dr. Houghton. 
Porrigo, Dr. A. T. Thomson. 
Pregnancy and Delivery, signs of, 

Dr. Montgomery. 
Prognosis, Dr. Ash. 
Prurigo, Dr. A. T. Thomson. 
Pseudo-Morbid Appearances, Dr. 

Todd. 
Psoriasis, Dr. Cumin. 
Ptyalism, Dr. Dunglison. 
Puerperal Diseases, Dr. Marshall 

Hall. 
Pulse, Dr. Bostock. 
Purpura, Dr. Goldie. 
Pus, Dr. Tweedie. 
Pyrosis, Dr. Kerr. 
Rape, Dr. Beatty. 



CONTENTS OF VOLUME IV. 



Refrigerants, Dr. A. T. Thomson. 
Rheumatism, Drs. Barlow and Dun 

glison. 
Rickets, Dr. Cumin. 
Roseola, Dr. Tweedie. 
Rubeola, Dr. Montgomery. 
Rupia, Dr. Corrigan. 
Scabies, Dr. Houghton. 
Scarlatina, Dr. Tweedie. 
Scirrhus, Dr. Carswell. 
Scorbutus, Dr. Kerr. 
Scrofula, Dr. Cumin. 
Sedatives, Drs. A. T. Thomson and 

Dunglison. 
Sex. Doubtful, Dr. Beatty. 
Small Pox, Dr. Gregory. 
Softening of Organs, Dr. Carswell. 
Somnambulism and Animal Magne- 
tism, Dr. Pritchard. 
Spermatorrhoea, Dr. Dunglison. 
Spinal Marrow, Diseases of the, Dr. 

Todd. 
Spleen, Diseases of the, Drs. Bigsby, 

and Dunglison. 



Statistics, Medical, Drs. Hawkins 
and Dunglison. 

Stethoscope, Dr. .Williams. 

Stimulants, Dr. A. T. Thomson. 

Stomach, Organic Diseases of, Dr. 
Houghton and Dunglison. 

Stomatitis, Dr. Dunglison. 

Strophulus, Dr. Dunglison. 

Succession of Inheritance, Legitima- 
cy, Dr. Montgomery, 

Suppuration, Dr. Todd. 

Survivorship, Dr. Beatty. 

Sycosis, Dr. Cumin. 

Symptomatology, Dr. Marshall Hall. 

Syncope, Dr. Ash. 

Tabes Mesenterica, Dr. Joy. 

Temperament, Dr. Pritchard. 

Tetanies, Dr. Dunglison. 

Tetanus, Dr. Symonds. 

Throat, Diseases of the, Dr. Tweedie, 

Tissue Adventitious. 

Tonics, Dr. A. T. Thomson. 

Toothache, Dr. Dunglison. 



Toxicology, Drs. Apjohn and Dungli- 
son. 
Transformations, Dr. Duesbury. 
Transfusion, Dr. Kay. 
Tubercle, Dr. Carswell. 
Tubercular Phthisis, Sir James Clark. 
Tympanitis, Dr. Kerr. 
Urine, Incontinence of, Dr. Cumin. 
Urine, Suppression of, Dr. Carter. 
Urine, Morbid States of, Dr. Bostock. 
Urine, Bloody, Dr. Goldie. 
Urticaria, Dr. Houghton. 
Uterus, Pathology of, Dr. Lee. 
Vaccination, Dr. Gregory. 
Varicella, Dr. Gregory. 
Veins, Diseases of, Dr. Lee. 
Ventilation, Dr. Brown. 
Wakefulness, Dr. Cheyne. 
Waters Mineral, Dr. T.Thompson. 
Worms, Dr. Joy. 
Yaws, Dr. Kerr.| 
Index, &c. 



The Publishers wish it to be particularly understood that this work not 
only embraces all the subjects properly belonging to 

PRACTICAL MEDICINE, 

but includes all the diseases and treatment of 

WOMEN AND CHILDREN, 

as well as all of particular importance on 

MATERIA MEDICA, THERAPEUTICS, 

AND 

MEDICAL JURISPRUDENCE, 

Thus presenting important claims on the profession from the greater 
extent *of subjects embraced in this than in other works on the mere 
Practice of Medicine; while, notwithstanding its BEAUTIFUL 
EXEC UTION, its REMARKABLE CHEAPNESS places it 
within the reach of all. 



LEA & BLANCHARD'8 PUBLICATIONS. 



Cyclopaedia of Practical Medicine, continued. 



The Publishers present a few of the notices which the work has received 
from the press in this country and in England. 



" We rejoice that this work is to be placed within 
the reach of the profession in this country, it being 
unquestionably one of very great value to the practi- 
tioner. This estimate of it has not been formed from 
a hasty examination, but after an intimate acquaint- 
ance derived from frequent consultation of it during 
the past nine or ten years. The editors are practition- 
ers of established reputation, and the list of contribu- 
tors embraces many of the most eminent professors 
and teachers of London, Edinburgh, Dublin and Glas- 
gow. It is, indeed, the great merit of this work that 
the principal articles have been furnished by practi- 
tioners who have not only devoted especial attention 
to the diseases about which they have written, but 
have also enjoyed opportunities for an extensive prac- 
tical acquaintance with them, and whose reputation 
carries the assurance of their competency justly to 
appreciate the opinions of others, while it stamps their 
own doctrines with high and just authority."— Ameri- 
can Medical Journal. 

"Do young physicians generally know what a trea- 
sure is offered to them in Dr. Dunglison's revised edi- 
tion? Without wishing to be thought importunate, we 
cannot very well refrain from urging upon them the 
claims of this highly meritorious undertaking."— Bos- 
ton Medical and Surgical Journal. 

"It has been to us, both as learner and teacher, a 
work for ready and frequent reference, one in which 
modern English medicine is exhibited in the most 
advantageous light, and with adaptations to various 
tastes and expectations." — Medical Examiner. 

"Such a work as this has long been wanting in this 
country. British medicine ought to have set itself 
forth in this way much sooner. We have often won- 
dered that the medical profession and the enterprising 
publishers of Great Britain did not, long ere this, 
enter upon such an undertaking as a Cyclopedia of 
Practical Medicine." — London Medical Gazette. 

"It is what it claims to be, a Cyclopedia, in which 
Practical Medicine is posted up to the present day, 
ami as such constitutes a storehouse of medical know- 
ledge upon which the student and practitioner may 
draw with equal advantage." — The Western Journal 
of Medicine and Surgery. 

"The Cyclopedia of Practical Medicine, a work 
which does honour to our country, and to which one 
is proud to see the names of so many provincial phy- 
sicians attached." — Dr. Hastings' Address to Pro- 
vincial Medical and Surgical Association. 

" Of the medical publications of the past year, one 
may be more particularly noticed, as partaking, from 
its extent and the number of contributors, somewhat 
of the nature of a national undertaking, namely, the 
* Cyclopedia of Practical Medicine. ' It accomplishes 
what has been noticed as most desirable, by present- 
ing, on several important topics of medical inquiry, 
full, comprehensive, and well digested expositions, 
showing the present state of our knowledge on each. 
In this country, a work of this kind was much wanted: 
and that now supplied cannot but be deemed an im- 
portant acquisition. The difficulties of the undertak- 
ing were not slight, and it required great energies to 
surmount them. These energies, however, were pos- 
sessed by the able and distinguished editors, who, 
with diligence and labour such as few can know or 
appreciate, have succeeded in concentrating in a work 



great extent and usefulness."— Dr. Barlow's Address 
to the Med. and Sur. Association. 

" For reference, it is above all price to every practi- 
tioner."— The Western Lancet. 

"This Cyclopedia is pronounced on all hands to be 
one of the most valuable medical publications of the 
day. It is meant to be a library of Practical Medicine. 
As a work of reference it is invaluable. Among the 
contributors to its pages, it numbers many of the most 
experienced and learned physicians of the age, and as 
a whole it forms a compendium of medical science 
and practice from which practitioners and students 
may draw the richest instruction."— Western Journ. 
of Med. and Surgery. 

"The contributors are very numerous, including 
the most distinguished physicians in the kingdom. 
The design of the work embraces practical articles of 
judicious length in Medicine, Therapeutics, Hygiene, 
&c, so that, within a small compass, and of easy re- 
ference, the student possesses a complete library, 
composed of the highest authorities. To the country 
practitioner, especially, a publication of this kind is 
of inestimable value."— U. S. Gazette. 

"When it is Considered that this great work em- 
braces three hundred original essays, from sources of 
the highest authority, we cannot but hope that our 
medical friends will offer all the requisite encourage- 
ment to the publishers."— Boston Medical and Sur- 
gical Journal. 

"In our last number we noticed the publication of 
this splendid work by Lea & Blanchard. We have 
since received three additional parts, an examination 
of which has confirmed us in our first impression, that 
as a work of reference for the practitioner— as a Cyclo- 
paedia of Practical Medicine— it is admirably adapted 
to the wants of the American profession. In fact, it 
might advantageously find a place in the library of 
any gentleman, who has leisure and taste for looking 
somewhat into the nature, causes, and cure of dis- 
eases." — Western Journal of Med. and Surgery. 

" The favourable opinion which we expressed on 
former occasions from the specimens then before us, 
is in no degree lessened by a further acquaintance 
with its scope and execution."— Medical Examiner. 

" The Cyclopedia must be regarded as the most 
complete work of Practical Medicine extant; or, at 
least in our language. The amount of information on 
every topic which it embraces, is posted up to the 
present time ; and so far as we are able to judge, it is 
generally more free from natural exclusiveness and 
prejudices, than is usually the case with British pub- 
lications. The getting up of the American edition is 
very creditable to the Publishers. It will compare very 
favourably with the English edition. In some re- 
spects, it is much to be preferred. During the original 
publication, many of the articles not being in readi- 
ness to be printed in proper alphabetical order, it be- 
came necessary To include them together in a single 
volume, as a supplement to the work. This difficulty 
is obviated in the American edition. On the whole, 
we advise those who desire a compendious collection 
of the latest and most important information in the 
various departments of Practical Medicine, including 
Midwifery, Materia Medica, Medical Jurisprudence, 
&c, to possess themselves of this work." — The Buf- 
falo Medical Journal. 



of moderate size, a body of practical knowledge of 

%* In reply to the numerous inquiries made to them respecting Tweedie's Library of Practical 
Medicine, the Publishers beg leave to state that its place is supplied, in a great measure, by the 
Cyclopaedia of Practical Medicine, a work much more extended in its plan and execution. The 
works are entirely distinct and by different authors. The u Lrbrary"consists of essays on diseases, 
systematically arranged. The "Cyclopaedia" embraces these subjects treated in a more extended 
manner, together with numerous interesting essays on all important points of Medical Jurispru- 
dence, Materia Medica, Therapeutics, Diseases of Women and Children, History of Medicine, &c, 
&c., by the first physicians of England, the whole arranged alphabetically for easier reference. 



LEA & BLANCHARD'S PUBLICATIONS. 



WATSON'S PRACTICE. 

NEW AND IMPROVED EDITION. 



Now Ready, 
LECTURES 

ON THE 

PRINCIPLES AND PRACTICE OF PHYSIC. 

DELIVERED AT KING'S COLLEGE, LONDON. 

By THOMAS WATSON, M. D., &c. &c. 

SECOND AMERICAN, FROM THE SECOND LONDON EDITION. 

REVISED, WITH ADDITIONS, 
By D. FRANCIS CONDIE, M. D„ 

•Author of a work on the " Diseases of Children," &c« 

In one Octavo Volume. 
Of nearly eleven hundred large pages, strongly bound with raised bands. 

The rapid sale of the first edition of this work is an evidence of its 
merits, and of its general favour with the American practitioner. To 
commend it still more strongly to the profession, the publishers have gone 
to a great expense in preparing this edition with larger type, finer paper, 
and stronger binding, with raised bands. It is edited with reference par- 
ticularly to American practice, by Dr. Condie ; and with these numerous 
improvements, the price is still kept so low as to be within the reach of 
all, and to render it among tne cheapest works offered to the profession. 
It has been received with the utmost favour by the medical press, both 
of this country and of England, a few of the notices of which, together 
with a letter from Professor Chapman, are submitted. 

"We know of no work better calculated foT being " We find that, from the great length we have gone 
placed in the hands of the student, and for a text book, in our analysis of tins work, we must close our notice 
and as such we are sure it will be very extensively of it here tor the present— not, however, without ex- 
adopted. On every important point the author seems pressing our unqualified approbation of the manner in 
to have posted up his knowledge to the day." — Ameri- which the author has performed his task. But it is as 
tan Medical Journal. a book of elementary instruction that we admire Dr. 

"In the Lectures of Dr. Watson, now republished Watson's work. "— Medico- Chirurgical Review. 

here in a large and closely-printed volume, we have '-One of the mosi practically useful books that ever 

a body of doctrine and practice of medicine well cal- was presented to the studeni— indeed a more admira- 

culated, by its intrinsic soundness and correctness of ble summary of general and special paihology, and of 

style, to instruct the student and younger practitioner, the application o^i therapeutics to diseases, we aTe free 

and improve members of the profession of every age." to say has not appeared for very many years. The 

—Bulletin of Medical Science. lecturer proceeds through the whole classification of 

'■We regard these Lectures as the best exposition human ills, a ca-pne ad eaktm. showing at every step 
of their subjects of any we remember to have read, anextens ve knowledge of his subject, with the ability 
The author is assuredly master of his art. His has of coiumun eating Ins precise ideas in a style remark- 
been a life of observation and study, and in this work able for its clearness and siinplicitv.'" N , Journal 
he has given us the matured results of these mental of Medicine and Surgery. 
efibrts."— New Orleans Medical Journal. 



LEA & BUNCH ARD'S PUBLICATIONS. 



WATSON'S PRACTICE— Continued. 



Philadelphia, September 21th, 1844. 
Watson's Practice of Physic, in my opinion, is among the most com- 
prehensive works on the subject extant, replete with curious and important 
matter, and written with great perspicuity and felicity of manner. As 
calculated to do much good, I cordially recommend it to that portion of 
the profession in this country who may be influenced by my judgment. 

N. CHAPMAN, M.D. 

Professor of the Practice and Tlxeory of Medicine 
in the University of Pennsylvania. 

(: We know not, indeed, of any work of the same ■ We are free to state that a careful examination of 
size that contains a greater amount of interesting and this volume has satisfied us that it merits all the corn- 
useful matter The author is evidently well acquainted mendation bestowed on it in this country and at 
with everything appertaining to the principles and home. It is a work adapted to the wants of young 
practice of medicine, and has incorporated the stores practitioners, combining, as it does, sound principles 
of his well stocked mind, in the work before us, so and substantial practice. It is not too much to say 
ably and agreeably, that it is impossible for the inte- that it is a representative of the actual state of medi- 
rest of the reader to flag for a moment. That they are cine as taught and practised by the most eminent phy- 
well adapted for such a purpose all must admit ; but sicians of the present day, and as such we would 
their sphere of usefulness may extend much beyond advise every one about embarking in the practice of 
this. We are satisfied, indeed' that no physician, well physic to provide himself with a copy of it."' — Western 
read and observant as he may be. can rise from their Journal of Medicine and Surgery. 
perusal without having added largely to his stock of "It is the production of a physician of undoubted 
valuable information."— Medical Exa??iiner. talent and great learning, and whose industry in per- 

"The medical literature of this country has been forming the most laborious duties of this profession 

mriched by a work of standard excellence, which we has been well known for a long series of years. 



can proudly hold up to our brethren of other countries 
as a representative of the natural state of British me- 
dicine, as professed and practised by our most en- 
lightened physicians. And. for our own parts, we are 
not only willing that our characters as scientific phy- 
sicians and skilful practitioners may be deduced from 



not to declare our belief that for sound, trustworthy 
principles, and substantial good practiced it cannot be 
paralleled by any similar production in any other 
country. * * * * We would advise no one to set 
himselt" down in practice unprovided with a copy." — 
British and Foreign Medical Review. 



Let us not forget to add that the style and general 
character of the work are peculiarly practical ; and 
the cases which Dr. Watson has from time to time 
introduced to illustrate his views, are highly appro- 
priate and interesting, and add much to the value of 
the work; and this certainty must be admitted to be 



the doctrines contained in this book, but we hesitate one of the great advantage's of casting this work in 

" the shape ot lectures, in which these cases assuredly 
appear more fitly, and in which thev are* introduced 



appei 

more easily and naturally than they could have been 
had the form of the work been different. Lastly, we 
are well pleased to observe that a strong vein of 
common sense, as well as good taste, runs through 
'We cannot refrain from calling the attention of the whole treatise, and sustains both the interest and 



our younger brethren, as soon as possible, to Dr. Wat- 
son's Lectures, if they want a safe and comprehensive 
guide to the study of practical medicine. 



the confidence of the reader throughout. 1 * — Edinburgh 
Medical and Surgical Journal. 

" In calling the attention of the profession to the ele- 



" In fact, to any of our more advanced brethren who gam volunWrecenily published by Lea & Blanchard 

wish to possess a commodious book of reference on — the lectures delivered at King's College. London, by 

any of the topics usually treated of in a course of lee- Dr. Watson— we do not suppose any one at all con- 

tures on the practice of physic, or who wish to have versant with the medical literature of the day to be 

a simple enunciation of any facts or doctrines which, unacquainted with its general character. Dr. W. de- 

from their novelty or their difficulty, the busy practi- livered these now celebrated lectures during the me- 

tioner may not have made himself master of amidst dical session of 1536-7. They have been revised by 

the all-absorbing toils of his professional career, we the author, and those who now study these erudite 

can recommend these lectures most cordially. Here productions will have them divested of any objection- 

we meet with none of those brilliant theories which able matter that might have formerly crept in through 

are so seductive to young men. because they are made inadvertence. There are ninety lectures, fully written, 



embracing the whole domain of human maladies, with 
their treatment, besides an appendix particularly re- 
markable for its richness in important practical infor- 
mation. We could not give even a tolerable synopsis 
of the subjects discussed in this great undertaking 
without materially entrenching on the limits assigned 
to other matter. * * * Open this huge, well-finished 



to explain every phenomenon, and save all the trouble 
of observation and reflection; here are no exclusive 
doctrines; none of those 

L Bubbles that glitter as they rise and break 
On vain Philosophy's all babbling spring.' 
But w r e have the sterling production of a liberal, well- 
stored and truly honest'mind. possessed of all that is volume wherever we may. the eye immediately rests 
currently known and established of professional know- on something that carries value on its fronL We are 
ledge, and capable of pronouncing a trustworthy and impressed at once with the strength and depih of the 
impartial judgment on those numerous points in which lecturer's views : he gains on our admiration in pro- 
Truth is yet obscured with false facts or false hypo- portion to the extent of our acquaintance with his 
theses." — Provincial Medical Journal. profound researches. Whoever owns this book will 
••The style is correct and pleasing, and the matter have an acknowledged treasure, if the combined wis- 
worthy the attention of all practitioners, young and dom of the highest authorities is appreciated."' — Boston 
old." — Western Lancet. Medical and Surgical Journal. 



HORNER'S ANATOM1T. 

SPECIAL ANATOMY AND HISTOLOGY. 

BY WILLIAM E. HORNER, MUX, 

Professor of Anatomy in the University of Pennsylvania. Member of the Imperial Medico-Chirurgical Academy 
of St. Petersburg, of the Am. Philosophical Society. <kc. 5cc. 
Sixth Edition, in two Volumes, 8vo. 
" Another edition of this standard work of Professor Horner has made its appearance to which 
many additions have been made, and upon which much labour has been bestowed by the author. — 
The additions are chiefly in the department of Histology, or Elementary Anatomy, and so import- 
ant are they that the Professor has added the term to the title of his work. Every part of this 
edition seems to have undergone the most careful revision, and its readers may rest assured of hav- 
ing the science of Anatomy fully brought up to the present day." — Am. Med. Journal. 



A XMEACtinFICENT AJSTD CHEAP WORK. 

SMITH & HORNER'S ANATOMICAL ATLAS. 

Just Published, Price Five Dollars in Parts. 



AN 

ANATOMICAL ATLAS 
ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. 

BY HENRY H. SMITH, M.D., 

Fellow of the College of Physicians, fyc. 
UNDER THE SUPERVISION OF 

WILLIAM E. HORNER, M.D., 

Professor of Anatomy in the University of Pennsylvania. 
In One large Volume, Imperial Octavo. 

This work is but just completed, having been delayed over the time intended by the great difficulty in giving 
to the illustrations the desired finish and perfection. It consists of five parts, whose contents are as follows: 

Part I. The Bones and Ligaments ? with one hundred and thirty engravings. 

Part II. The Muscular and Dermoid Systems, with ninety-one engravings. 

Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. 

Part IV. The Organs of Respiration and Circulation, with ninety-eight engravings. 

Part V. The Nervous System and the Senses, with one hundred and twenty-six engravings. 
Forming altogether a complete System of Anatomical Plates, of nearly 

. SIX HUNDRED AND FIFTY FIGURES, 

executed in the best style of art, and making one large imperial octavo volume. Those who do not want it in 
parts can have the work bound in extra cloth or sheep at an extra cost. 

This work possesses novelty both in the design and the execution. It is the first attempt to apply engraving 
on wood, on a large scale, to the illustration of human anatomy, and the beauty of the parts issued induces the 
publishers to natter themselves with the hope of the perfect success of their undertaking. The plan of the 
work is at once novel and convenient. Each page is perfect in itself, the references being immediately under 
the figures, so that the eye takes in the whole at a glance, and obviates the necessity of continual reference 
backwards and forwards. The cuts are selected from the best and most accurate sources ; and, where neces- 
sary, original drawings have been made from the admirable Anatomical Collection of the University of Penn- 
sylvania. It embraces all the late beautiful discoveries arising from the use of the microscope in the investi- 
gation of the minute structure of the tissues. 

In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they 
now present it to the profession, with the full confidence that it will be deemed all that is wanted in a scientific 
and artistical point of view, while, at the same time, its very low price places it within the reach of all. 

It is 'particularly adapted to supply the place of skeletons or subjects, as the prof ession mill see by examining the list 
of plates now annexed. 



" These figures are well selected, and present a complete and accurate representation of that wonderful fabric, 
the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its 
superb artistical execution^ have been already pointed out. We must congratulate the student upon the 
completion of this atlas, as it is the most convenient work of the kind that has yet appeared; and, we must 
add, the very beautiful manner in which it is ' got up' is so creditable to the country as to be flattering to our 
national pride." — American Medical Journal. 

"This is an exquisite volume, and a beautiful specimen of art. We have numerous Anatomical Atlases, 
but we will venture to say that none equal it in cheapness, and none surpass it in faithfulness and spirit. We 
strongly recommend to our friends, both urban and suburban, the purchase of this excellent work, for which 
both editor and publisher deserve the thanks of the profession." — Medical Examiner. 

"We would strongly recommend it, not only to the student, but also to the working practitioner, who, 
although grown rusty in the toils of his harness, still has the desire, and often the necessity ; of refreshing his 
knowledge in this fundamental part of the science of medicine." — New York Journal of Medicine and Surg. 

" The plan of this Atlas is admirable, and its execution superior to any thing of the kind before published in 
this country. It is a real labour-saving affair, and we regard its publication as the greatest boon that could be 
conferred on the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy 
means of recalling the details learned in the dissecting room, and which are soon forgotten." — American Medi- 
cal Journal. 

" It is a beautiful as well as particularly useful design, which should be extensively patronized by physicians, 
surgeons and medical students." — Boston Med. and Surg. Journal. 

" It has been the aim of the author of the Atlas to comprise in it me valuable points of all previous works, to 
embrace the latest microscopical observations on the anatomy of the tissues, and by placing it at a moderate 
price to enable all to acquire it who may need its assistance in the dissecting or operating room, or other field 
of practice." — Western Journal of Med. and Surgery. 

"These numbers complete the series of this beautiful work, which fully merits the praise bestowed upon the 
earlier numbers. We regard all the engravings as possessing an accuracy only equalled by their beauty, 
and cordially recommend the work to all engaged in the study of anatomy." — New York Journal of Medicine 
and Surgery. 

" A more elegant work than the one before us could not easily be placed by a physician upon the table of 
his student." — Western Journal of Medicine and Surgery. 

"We were much pleased with Part I, but the Second Part gratifies us still more, both as regards the attract- 
ive nature of the subject, (The Dermoid and Muscular Systems,) and the beautiful artistical execution of the 
.1 lustrations. We have here delineated the most accurate microscopic views of some of the tissues, as, for 
instance, the cellular and adipose tissues, the epidermis, rete mucosum and cutis vera, the sebaceous and 
perspiratory organs of the skin, the perspiratory glands and hairs of the skin, and the hair and nails. Then 
follows the "general anatomy of the muscles, and, lastly, their separate delineations. We would recommend 
this Anatomical Atlas to our readers in the very strongest terms." — New York Journal of Medicine and Suf* 
gery. 



LIST OP 

THE ILLUSTRATIONS 

EMBRACING 

SIX HUNDRED AND THIRTY-SIX FIGURES 

IN SMITH AND HORNER'S ATLAS. 



a hlghly-jixished vlew of the bones of the head, 
View of Cuvier's Anatomical Theatre, . . . . 



facing the title-page 
. . . . vignette 



PART I.— BONES AND LIGAMENTS. 



Fig. Fig. 

1 Front view of adult skeleton. 64 

2 Back view of adult skeleton. 65 

3 Foetal skeleton. 66 

4 Cellular structure of femur. 67 

5 Cellular and compound structure of tibia. 68 

6 Fibres of compact matter of bone. 70 

7 Concentric lamella of bone. 71 

8 Compact matter under the microscope. 72 

9 Haversian canals and lacunae of bone. 73 

10 Vessels of compact matter. 75 

11 Minute structure of bones. 77 

12 Ossification in cartilage. 7$ 

13 Ossification in the scapula. 79 

14 Puncta ossificationis in femur. 80 

15 Side view of the spinal column. 81 

16 Epiphyses and diaphysis of bone. 82 

17 External periosteum. 84 

18 Punctum ossificationis in the head. 85 

19 A cervical vertebra. 86 

20 The atlas. 21 The dentata. 88 

22 Side view of the cervical vertebrae. 90 

23 Side view of the dorsal vertebrae. 91 

24 A dorsal vertebra. 92 

25 Side view of the lumbar vertebrae. 94 

26 Side view of one of the lumbar vertebrae. 95 

27 Perpendicular view of the lumbar vertebrae. 96 

28 Anterior view of sacrum. 97 

29 Posterior view of sacrum. 98 

30 The bones of the coccyx. 99 

31 Outside view of the innominatum. 100 

32 Inside view of the innominatum. 101 

33 Anterior view of the male pelvis. 102 

34 Anterior view of the female pelvis. 103 

35 Front of the thorax. 36 The first rib. 104 

37 General characters of a rib. 105 

38 Front view of the sternum. 106 

39 Head of a Peruvian Indian. 107 

40 Head of a Choctaw Indian. 108 

41 Front view of the os frontis. 109 

42 Undar surface of the os frontis. 110 

43 Internal surface of the os frontis. Ill 

44 External surfaee of the parietal bone.s 112 

45 Internal surface of the parietal bone. 113 

46 External surface of the osoccipitis. 114 

47 Internal surface of the os occipitis. 115 

48 External surface of the temporal bone. 116 

49 Internal surface of the temporal bone. 117 

50 Internal surface of the sphenoid bone. 118 

51 Anterior surface of the sphenoid bone. 119 

52 Posterior surface of the ethmoid bone. 120 

53 Front view of the bones of the face. 121 

54 Outside of the upper maxilla. 122 

55 Inside of the upper maxilla. 123 
5fi Posterior surface of the palate bone. 124 

57 The nasal bones. 125 

58 The os unguis. 59 Inferior spongy bone. 126 
60 Right malar bone. 61 The vomer. 127 

62 Inferior maxillary bone. 128 

63 Sutures of the vault of the cranium. 



Sutures of the posterior of the cranium. 

Diploe of the cranium. 

Inside of the base of the cranium. 

Outside of the base of the cranftim. 

The facial angle. 69 The fontanels. 

The os hyoides. 

Posterior of the scapula. 

Axillary margin of the scapula. 

The clavicle. 74 The humerus. 

The ulna. 76 The radius. 

The bones of the carpus. 

The bones of the hand. 

Articulation of the carpal bones. 

Anterior view of the femur. 

Posterior view of the femur. 

The tibia. 83 The fibula. 

Anterior view of the patella. 

Posterior view of the patella. 

The os calcis. 87 The astragalus. 

The naviculare. 89 The cuboid bone. 

The three cuneiform bones. 

Top of the foot. 

The sole of the foot. 93 Cells in cartilage. 

Articular cartilage under the microscope. 

Costal cartilage under the microscope. 

Magnified section of cartilage. 

Magnified view of fibro-cartilage. 

White fibrous tissue. 

Yellow fibrous tissue. 

Ligaments of the jaw. 

Internal view of the same. 

Vertical section of the same. 

Anterior vertebral ligaments. 

Posterior vertebral ligaments. 

Yellow ligaments. 

Costo- vertebral ligaments. 

Occipito-altoidien ligaments. 

Posterior view of the same. 

Upper part of the same. 

Moderator ligaments. 

Anterior pelvic ligaments. 

Posterior pelvic ligaments. 

Sterno-clavicular ligaments. 

Scapulo-humeral articulation. 

External view of elbow joint. 

Internal view of elbow joint. 

Ligaments of the wrist. 

Diagram of the carpal synovial membrane 

Ligaments of the hip joint. 

Anterior view of the knee joint. 

Posterior view of the knee joint. 

Section of the right knee joint. 

Section of the left knee joint. 

Internal side of the ankle joint. 

External side of the ankle joint. 

Posterior view of the ankle joint 

Ligaments of the sole of the foot 

Vertical section of the foot. 



PART II.— DERMOID AND MUSCULAR SYSTEMS. 



129 Muscles on the front of the body, full length. 
131 Muscles on the back of the body, full length. 

130 The cellular tissue. 132 Fat vesicles. 



133 Blood-vessels of fat. 

134 Cell membrane of fat vesicles. 

135 Magnified view of the epidermis. 



Illustrations to Smith and Horner's rftlas, continued. 



Fig. 

136 

137 

1-38 

139 

140 

141 

142 

HS 

145 

146 

147 

148 

149 

151 

152 

153 

154 

155 

156 

157 

158 

159 

160 

161 

162 

163 

164 

165 

166 

167 

168 

169 

170 

171 

172 

173 

175 

176 

177 

178 

179 



Cellular tissue of the skin. 

Rete mucosum, &c, of foot. 

Epidermis and rete mucosum. 

Cutis vera, magnified. 

Cutaneous papilla?. 

Internal face of cutis vera. 

Integuments of foot under the microscope. 

Cutaneous glands. 144 Sudoriferous organs. 

Sebaceous glands and hairs. 

Perspiratory gland magnified. 

A hair under the microscope. 

A hair from the face under the microscope. 

Follicle of a hair. 150 Arteries of a hair. 

Skin of the beard magnified. 

External surface of the thumb nail. 

Internal surface of the thumb nail. 

Section of nail of fore finger. 

Same highly magnified. 

Development of muscular fibre. 

Another view of the same. 

Arrangement of fibres of muscle. 

Discs of muscular fibre. 

Muscular fibre broken transversely. 

Striped elementary fibres magnified. 

Striae of fibres from the heart of an ox. 

Transverse section of biceps muscle. 

Fibres of the pectoralis major. 

Attachment of tendon to muscle. 

Nerve terminating in muscle. 

Superficial muscles of face and neck. 

Deep-seated muscles of face and neck. 

Lateral view of the same. 

Lateral view of superficial muscles of face. 

Lateral view of deep-seated muscles of face. 

Tensor tarsi or muscle of Horner. 

Pterygoid muscles. 174 Muscles of neck. 

Muscles of tongue. 

Fascia profunda colli. 

Superficial muscles of thorax. 

Deep-seated muscles of thorax. 

Frontview of abdominal muscles. 



Fig. 

180 Side view of abdominal muscles. 

181 External parts concerned in hernia. 

182 Internal parts concerned in hernia. 

183 Deep-seated muscles of trunk. 

184 Inguinal and femoral rings. 

185 Deep-seated muscles of neck. 

186 Superficial muscles of back. 

187 Posterior parietes of chest and abdomen. 

188 Under side of diaphragm. 

189 Second layer of muscles of back. 

190 Muscles of vertebral gutter. 

191 Fourth layer of muscles of back. 

192 Muscles behind cervical vertebrae. 

193 Deltoid muscle. 

194 Anterior view of muscles of shoulder. 

195 Posterior view of muscles of shoulder. 

196 Another view of the same. 

197 Fascia brachialis. 

198 Fascia of the fore-arm. 

199 Muscles on the back of the hand. 

200 Muscles on the front of the arm. 

201 Muscles on the back of the arm. 
902 Pronators of the fore-arm. 

203 Flexor muscles of fore-arm. 

204 Muscles in palm of hand. 

205 Deep flexors of the fingers. 

206 Superficial extensors. 

207 Deep-seated extensors. 

208 Rotator muscles of the thigh. 
909 Muscles on the back of the hip. 

210 Deep muscles on the front of thigh. 

211 Superficial muscles on the front of thigh. 

212 Muscles on the back of the thigh. 

213 Muscles on front of leg. 

214 Muscles on back of leg. 

215 Deep-seated muscles on back of leg. 

216 Muscles on the sole of the foot. 

217 Another view of the same. 

218 Deep muscles on front of arm. 

219 Deep muscles on back of arm. 



PART IIL— ORGANS OF DIGESTION AND GENERATION. 



220 Digestive organs in their whole length. 

221 Cavity of the mouth. 

222 Labial and buccal glands. 

223 Teeth in the upper and lower jaws. 

224 Upper jaw, with sockets for teeth. 

225 Lower jaw, with sockets for teeth. 

226 Under side of the teeth in the upper jaw. 

227 Upper side of the teeth in the lower jaw. 

228 to 235. Eight teeth, from the upper jaw. 
236 to 243. Eight teeth from the lower jaw. 
244 to 251. Side view of eight upper jaw teeth* 
252 to 259. Side view of eight lower jaw teeth. 
260 to 265. Sections of eight teeth. 

266 to 267. Enamel and structure of two of the 
teeth. 

268 Bicuspis tooth under the microscope. 

269 Position of enamel fibres* 

270 Hexagonal enamel fibres. 

271 Enamel fibres very highly magnified. 

272 A very highly magnified view of fig. 268. 

273 Internal portion of the dental tubes. 

274 External portion of the dental tubes. 

275 Section of the crown of a tooth. 

276 Tubes at the root of a bicuspis. 

277 Upper surface of the tongue. 

278 Under surface of the tongue. 

279 Periglottis turned off the tongue. 

280 Muscles of the tongue. 

281 Another view of the same. 

282 Section of the tongue. 

283 Styloid muscles, &c. 

284 Section of a gustatory papilla. 

285 View of another papilla. 

286 Root of the mouth and soft palate. 

287 Front view of the pharynx and muscles. 



288 Back view of the pharynx and muscles. 

289 Under side of the soft palate. 

290 A lobule of the parotid gland. 

291 Salivary glands. 

292 Internal surface of the pharynx. 

293 External surface of the pharynx. 

294 Vertical section of the pharynx. 

295 Muscular coat of the oesophagus. 

296 Longitudinal section of the (esophagus. 

297 Parietes of the abdomen. 

298 Reflexions of the peritoneum. 

299 Viscera of the chest and abdomen. 

300 Another view of the same. 

301 The intestines in situ. 

302 Stomach and oesophagus. 

303 Frontview Of the stomach. 

304 Interior of the stomach. 

305 The stomach*and duodenum. 

306 Interior of the duodenum. 

307 Gastric glands. 

308 Mucous coat of the stomach. 

309 An intestinal villus. 310 Its vessels. 

311 Glands of the stomach magnified. 

312 Villus and lacteal. 

313 Muscular coat of the ileum. 

314 Jejunum distended and dried. 

315 Follicles of Lieberkuhn 

316 Glands of Brunner. 317 Intestinal glands. 
318 Valvulse conniventes. 319 Ileo-colic valve. 

320 Villi and intestinal follicles. 

321 Veins of the ileum. 

322 Villi filled with chyle. 323 Peyer*s glands 

324 Villi of the jejunum under the microscope. 

325 The caecum. 326 The mesocolon and colon, 
327 Muscular coat of the colon. 



Illustrations to Smith and Horner's Atlas continued. 



Fig- 

328 

329 

330 

33l" 

332 

333 

334 

335 

336 

337 

338 

539 

340 

341 

343 

344 

346 

347 

348 

349 

350 

351 

352 

353 

354 

356 

357 

358 

359 

361 

362 

363 

S64 

365 

366 

368 

370 

371 

372 



Fig. 

Muscular fibres of the rectum. 373 

Curvatures of the large intestine. 374 

Mucous follicles of the rectum. 375 

Rectal pouches. 376 

Follicles of the colon, highly magnified. 377 

Folds and follicles of the stomach. 378 

Follicles, &c. of the jejunum. 379 

Villi and follicles of the ileum. 380 

Muciparous glands of the stomach. 381 

Ileum inverted, &c. 382 

Glands of Peyer magnified. 383 

Peritoneum of the liver injected. 384 

Liver in situ. 385 

Under surface of the liver. 342 Hepatic vein. 386 

Parenchyma of the liver. 387 

Hepatic blood-vessels. 345 Biliary ducts. 388 

Angular lobules of the liver. S89 

Hounded hepatic lobules. 390 

Coats of the gall bladder. S91 

Gall bladder injected. 392 

Vena portarum. 393 

External face of the spleen. 394 

Internal face of the spleen. 395 

Splenic vein. 396 

Pancreas &c, injected. 355 Urinary organs. 397 

Right kidney and capsule. 398 

Left kidney and capsule. 399 

Kidney under the microscope. 400 

The ureter. 360 Section of right kidney. 401 

Section of the left kidney. 402 

Pyramids of Malpighi. 403 

Lobes of the kidney. 404 

Renal arteries, &c, injected. 405 

Section of the kidney highly magnified. 406 

Copora Malpighiana. 367 Same magnified. 407 

Tubuli uriniferi. 369 Corpora Wolffiana. 408 

The bladder and urethra, full length. 409 

Muscular coat of the bladder. 410 
Another view of the same. 



Sphincter apparatus of the bladder. 

Prostate and vesiculse seminales. 

Side view of the pelvic viscera. 

The glans penis injected. 

The penis distended aud dried. 

Section of the same. 

Vertical section of the male pelvis, &c. 

Septum pectiniforme. 

Arteries of the penis. 

Vertical section of the urethra. 

Vesiculae seminales injected. 

Muscles of the male perineum. 

Interior of the pelvis, seen from above. 

Testis in the foetus. 

Diagram of the descent of the testis. 

Tunica vaginalis testis. 

Transverse section of the testis. 

Relative position of the prostate. 

Vas deferens. 

Vertical section of the bladder. 

The testicle injected with mercury. 

Another view. 

Minute structure of the testis. 

Female generative organs. 

Another view of the same. 

External organs in the foetus. 

Muscles of the female perineum. 

Side view of the female pelvis, &c. 

Relative position of the female organs.' 

Section of the uterus, &c. 

Fallopian tubes, ovaries, Stc. 

Front view of the mammary gland. 

The same after removal of the skin. 

Side view of the breast. 

Origin of lactiferous ducts. 

Lactiferous tubes during lactation. 

Minute termination of a tube. 

Ducts injected ; after Sir Astley Cooper. 



PART IV.— ORGANS OF RESPIRATION AND CIRCULATION. 



411 Front view of the thyroid cartilage. 

412 Side view of the thyroid cartilage. 

413 Posterior of the arytenoid cartilage. 

414 Anterior of the arytenoid cartilage. 

415 Epiglottis cartilage. 416 Cricoid cartilage. 

417 Ligaments of the larynx. 

418 Side view of the same. 

419 The thyroid gland. 

420 Internal surface of the larynx. 

421 Crico-thyroid muscles. 

422 Crico-arytenoid muscles. 

423 Articulations of the larynx. 

424 Vertical section of the larynx. 

425 The vocal ligaments. 426 Thymus gland. 

427 Front view of the lungs. 

428 Back view of the lungs. 

429 The trachea and bronchia. 
450 Lungs, heart, &c. 

431 First appearance of the blood-vessels. 

432 Capillary vessels magnified. 

433 Another view of the same. 

434 Blood globules. 

435 Another view of the same. 
456 The mediastina. 

437 Parenchyma of the lung. 

438 The heart and pericardium. 

439 Anterior view of the heart. 

440 Posterior view of the heart. 

441 Anterior view of its muscular structure. 

442 Posterior view of the same. 

443 Interior of the right ventricle. 

444 Interior of the left ventricle. 

445 Mitral valve, the size of life. 

446 The auriculo-ventricular valves. 

447 Section of the ventricles. 

448 The arteries from the arch of the aorta. 

449 The arteries of the neck, the size of life. 



450 The external carotid artery. 

451 A front view of arteries of "head and neck. 

452 The internal maxillary artery. 

453 Vertebral and carotid arteries with the aorta. 

454 Axillary and brachial arteries. 

455 The brachial artery. 

456 Its division at the elbow. 

457 One of the anomalies of the brachial artery. 

458 Radial and ulnar arteries. 

459 Another view of the same. 

460 The arcus sublimis and profundus. 

461 The aorta in its entire length. 

462 Arteries of the stomach and liver. 

463 Superior mesenteric artery. 

464 Inferior mesenteric artery. 

465 Abdominal aorta. 

466 Primitive iliac and femoral arteries. 

467 Perineal arteries of the male. 

468 Position of the arteries in the inguinal canal. 

469 Internal iliac artery. 470 Femoral artery. 

471 Gluteal and ischiatic arteries. 

472 Branches of the ischiatic artery. 

473 Popliteal artery. 

474 Anterior tibial artery. 

475 Posterior tibial artery. 

476 Superficial arteries on the top of the foot. 

477 Deep-seated arteries on the top of the foot. 

478 Posterior tibial artery at the ankle. 

479 The plantar arteries. 

480 Arteries and veins of the face and neck. 

481 Great vessels from the heart. 

482 External jugular vein. 

483 Lateral view of the vertebral sinuses. 

484 Posterior view of the vertebral sinuses. 

485 Anterior view of the vertebral sinuses. 

486 Superficial veins of the arm. 

487 The same at the elbow. 



Illustrations to Smith and Horner's Atlas continued. 



Fig. 

488 The veins of the hand. 

489 The great veins of the trunk. 

490 Positions of the arteries and veins of the trunk. 

491 The vense cav#. 492 The vena portarum. 

493 Deep veins of the back of the leg. 

494 Positions of the veins to the arteries in the 

arm. 495 Superficial veins of the thigh. 

496 Saphena vein. 

497 Superficial veins of the leg. 

498 Lymphatics of the upper extremity. 



Fig. 

499 The lymphatics and glands of the axilla, 

500 The femoral and aortic lymphatics. 

501 The lymphatics of the small intestines. 

502 The thoracic duct. 

503 The lymphatics of the groin. 

504 Superficial lymphatics of the Liigh. 

505 Lymphatics of the jejunum. 

506 Deep lymphatics of the thigh. 

507 Superficial lymphatics of the leg. 

508 Deep lymphatics of the leg. 



PART V.— THE NERVOUS SYSTEM AND SENSES. 



509 Dura mater cerebri and spinalis. 

510 Anterior view of brain and spinal marrow. 

511 Anterior view of the spinal marrow, &c. 

512 Lateral view of the spinal marrow, &c. & 

513 Posterior view of the spinal marrow, &c. 

514 Decussation of Mitischelli. 

515 Origins of the spinal nerves. 

516 Anterior view of spinal marrow and nerves. 

517 Posterior view of spinal marrow and nerves. 

518 Anterior spinal commissure. 

519 Posterior spinal commissure. 

520 Transverse section of the spinal marrow. 

521 Dura mater and sinuses. 

522 Sinuses laid open. 

523 Sinuses at the base of the cranium. 

524 Pons Varolii, cerebellum, &c. 

525 Superior face of the cerebellum. 

526 Inferior face of the cerebellum. 

527 Another view of the cerebellum. 

528 View of the arbor vitse, &c. 

529 Posterior view of the medulla oblongata. 

530 A vertical section of the cerebellum. 

531 Another section of the cerebellum. 

532 Convolutions of the cerebrum. 

533 The cerebrum entire. 

534 A section of its base. 

535 The corpus callosum entire. 

536 Diverging fibres of the cerebrum, &c. 

537 Vertical section of the head. 

538 Section of the corpus callosum. 

539 Longitudinal section of the brain. 

540 View of a dissection by Gall. 

541 The commissures of the brain. 

542 Lateral ventricles. 

543 Corpora striata-fornix, &c. 

544 Fifth ventricle and lyra. 

545 Anotherjjview of the lateral ventricles. 

546 Another' view of the ventricles. 

547 Origins of the 4th and 5th pairs of nerves. 

548 The circle of Willis. 

549 A side view of the nose. 

550 The nasal cartilages. 

551 Bones and cartilages of the nose. 

552 Oval cartilages, kc. 

553 Schneiderian membrane. 

554 External parietes of the left nostril. 

555 Arteries of the nose. 

556 Pituitary membrane injected. 

557 Posterior P^es. 558 Front view of the eye. 

559 Side view of the eye. 

560 Posterior view of the eyelids, &c. 

561 Glandulse palpebrarum. 

562 Lachrymal canals. 

563 Muscles of the eyeball. 

564 Side view of the eyeball. 

565 Longitudinal section of the eyeball. 

566 Horizontal section of the eyeball. 

567 Anterior view of a transverse section. 

568 Posterior view of a transverse section. 

569 Choroid coat injected. 

570 Veins of the choroid coat. 

471 The iris, 573 Thejrefr'ia and lensu 



573 External view of the same. 

574 Vessels in the conjunctiva. 

575 Retina, injected and magnified. 

576 Iris, highly magnified. 

577 Vitreous humour and lens. 

578 Crystalline adult lens. 

579 Lens of the foetus, magnified. 

580 Side view of the lens. 

581 Membrana pupillaris. 

582 Another view of the same. 

583 Posterior view of the same. 

584 A view of the left ear. 

585 Its sebaceous follicles. 

586 Cartilages of the ear. 

587 The same with its muscles. 

588 The cranial side of the ear. 

589 Meatus auditorius externus, &c 

590 Labyrinth and bones of the ear. 

591 Full view of the malleus. 592 The incus. 

593 Another view of the malleus. 

594 A front view of the stapes. 

595 Magnified view of the stapes. 

596 Magnified view of the incus. 

597 Cellular structure of the malleus. 

598 Magnified view of the labyrinth. 

599 Natural size of the labyrinth. 

600 Labyrinth laid open and magnified. 

601 Labyrinth, natural size. 

602 Labyrinth of a foetus. 

603 Another view of the same. 

604 Nerves of the labyrinth. 
005 A view of the vestibule, &c. 

606 Its soft parts, &c. 

607 An ampulla and nerve. 

608 Plan of the cochlea. 

609 Lamina spiralis, he. 

610 The auditory nerve. 

611 Nerve on the lamina spiralis. 

612 Arrangement of the cochlea. 

613 Veins of the cochlea, highly magnified. 

614 Opening of the Eustachian tube in the throat 

615 Portio mollis of the seventh pair of nerves 

616 The olfactory nerves. 

617 The optic and seven other pairs of nerves. 

618 Third, fourth and sixth pairs of nerves. 

619 Distribution of the fifth pair. 

620 The facial nerve. 

621 The hypo-glossal nerves. 

622 A plan of the eighth pair of nerves. 

623 The distribution of the eighth pair. 

624 The great sympathetic nerve. 

625 The brachial plexus. 

626 Nerves of the front of the arm. 

627 Nerves of the back of the arm. 

628 Lumbar and ischiatic nerves. 

629 Posterior branches to the hip, &c, 

630 Anterior crural nerve. 

631 Anterior tibial nerve. 

632 Branches of the popliteal nerve. 

633 Posterior tibial nerve on the leg. 

634 Posterior tibial nerve on the foot* 



LEA & BLANCHARD'S PUBLICATIONS. 15 

PROFESSOR DUNGLISON'S WORKS. 

The Worlds of Professor Dunglison on various departments of Medicine are here presented. — 
Nearly all of them are extensively used as text books in the branches of science to which they re- 
late, and the profession and students may rely upon the great care and accuracy of the author in 
having each new edition of his works posted up to the day of publication. 

A NEW EDITION OP THE STANDARD MEDICAL DICTIONARY. 

A DICTIONARY OF "MEDICAL SCIENCE; 

CONTAINING A CONCISE ACCOUNT OF THE VARIOUS SUBJECTS AND TERMS, WITH 
THE FRENCH AND OTHER SYNONYMES, NOTICES OF CLIMATES AND OF CELE- 
BRATED MINERAL WATERS, FORMULAE FOR VARIOUS OFFICINAL AND EMPIRI- 
CAL PREPARATIONS, &c. 
Fifth Edition, Extensively Modified and Improved over former Editions. 
BY ROBLEY DUNGLISON, M.D. 
Professor of the Institutes of Medicine, &c, in Jefferson Medical College, Philada. ; Secretary to 
the American Philosophical Society, &c, &c. 
In one large royal octavo volume of nearly 800 double columned pages, and bound with raised bands. 
The author's object has not been to make the work a mere Lexicon, or Dictionary of terms, but 
to afford, under each, a condensed view of its various medical relations, and thus to render the 
work a complete epitome of the existing condition of medical science. This he has been in a great 
measure enabled to do, as the work is not stereotyped, by adding in each successive edition all 
new and interesting matters or whatever of importance had been formerly omitted. To show 
the advantage of this, it need only be remarked that in the present work will be found at least two 
thousand subjects and terms not embraced in the third edition. 

" To execute such a work requires great erudition, unwearied industry, and extensive research; 
and we know no one who could bring to the task higher qualifications of this description than Pro- 
fessor Dunglison." — American MedicalJournal. 

DUNGLISON'S PRACTICE^ A NEW EDITION, 

THE PRACTICE OF MEDICINE, 

OR A TREATISE ON SPECIAL PATHOLOGY AND THERAPEUTICS. 

BY ROBLEY DUNGLISON, M.D., 
Second Edition, carefully Revised and with Additions. 
In Two Large Octavo Volumes of over thirteen hundred pages. 
The Publishers annex a condensed statement of the Contents: — Diseases of the Mouth, Tongue, 
Teeth, Gums, Velum Palati and Uvula, Pharynx and (Esophagus, Stomach, Intestines, Peritoneum, 
Morbid Productions in the Peritoneum, and Intestines. — Diseases of the Larynx and Trachea, Bron- 
chia and Lungs, Pleura, Asphyxia. — Morbid conditions of the Blood, Diseases of the Heart and 
Membranes, Arteries, Veins, Intermediate or Capillary Vessels, — Spleen, Thyroid Gland, Thymus 
Gland, and Supra Renal Capsules, Mesenteric Glands, — Salivary Glands, Pancreas, Biliary Appara- 
tus, Kidney, Ureter, Urinary Bladder. — Diseases of the Skin, Exanthematous, Vesicular, Bullar, 
Pustular, Papular, Squamous, Tuberculous, Maculae, Syphilides. — Organic Diseases of the Nervous 
Centres, Neuroses, Diseases of the Nerves. — Diseases of the Eye, Ear, Nose. — Diseases of the 
Male and Female Organs of Reproduction. Fever, — Intermittent, Remittent, Continued, Eruptive, 
Arthritic. — Cachexies, Scrofulous, Scorbutic, Chlorotic, Rhachitic, Hydropic and Cancerous. 

This work has been introduced as a text-book in many of the Medical Colleges, 
and the general favour with which it has been received, is a guarantee of its value 
to the practitioner and student. 

" In the volumes before us ? Dr. Dunglison has proved that his acquaintance with the present facts 
and doctrines, wheresoever originating, is most extensive and intimate, and the judgment, skill, 
and impartiality with which the materials of the work have been collected, weighed, arranged, and 
exposed, are strikingly manifested in every chapter. Great care is everywhere taken to indicate 
the source of information, and under the head of treatment, formulae of the most appropriate reme- 
dies are everywhere introduced. We congratulate the students and junior practitioners of Ame- 
rica, on possessing in the present volumes, a work of standard merit, to which they may confidently 
refer in their doubts and difficulties." — British and Foreign Medical Review, for July, 1842. 

" Since the foregoing observations were written, we have received a second edition of Dungli- 
son's work, a sufficient indication of the high character it has already attained in America, and 
justly attained." — British and Foreign Medical Review, for October, 1844. 

"We hail the^ appearance of this work, which has just been issued from the prolific press of 
Messrs. Lea fe Blanchard of Philadelphia, with no ordinary degree of pleasure. Comprised in two 
large and closely printed volumes, it exhibits a more full, accurate, and comprehensive digest of 
the existing state of medicine than any other treatise with which we are acquainted in the English 
language. It discusses many topics — some of them of great practical importance, which are en- 
tirely omitted in the writings of Eberle, Dewees, Hosack, Graves, Stokes, Mcintosh, and Gregory ; 
and it cannot fail, therefore, to be of great value, not only to the student, but to the practitioner, as 
it affords him ready access to information of which he 6tands in daily need in the exercise of his 
profession. " — Louisville Journal, 



16 LB A & BLANOHARD'S PUBLICATIONS. 

PROFESSOR DUEFGLISON'S WORKS— Continued. 

GENERAL THEiWEyTlGsTAND MATERIA ME8ICA, 

ADAPTED FOR A MEDICAL TEXT-BOOK. 

BY ROBLEY DUNGLISON, M.D., 

In two Volumes ,.8vo. * 

" The subject of Materia Medica has been handled by our author with more than usual judgment. 
The greater part of treatises on that subject are, in effect expositions of the natural and chemical 
history of the substances used in medicine, with very brief notices at all of the indications they are 
capable of fulfilling, and the general principles of Therapeutics. Dr. Dunglison, very wisely, in 
our opinion, has reversed all this, and given his principal attention to the articles of the Materia 

Medica as medicines In conclusion, we strongly recommend these volumes to our readers. — 

No medical student on either side of the Atlantic should be without them."— Forbes* British and 
Foreign Medical Review. 

" Our junior brethren in America will find in these volumes of Professor Dunglison a c Thesau- 
rus Medic aminum,' more valuable than a large purse of gold." — Medico-Chirur gical Review, for 
January , 1S45. 

WITH UPWARDS OF THREE HUNDREp ILLUSTRATIONS, 

BY ROBLEY DUNGLISON, M.D., 

Fifth Edition, Greatly Modified and Improved, in 2 Vols, of 1304 Large Octavo Pages. 

" We have on two former occasions, brought this excellent work under the notice of our readers, 
and we have now only to say that, instead of falling behind in the rapid march of physiological 
science, each edition brings it nearer to the van. Without increasing the bulk of the treatise, the 
author lias contrived to introduce a large quantity of new matter into this edition from the works of 
Valentin, Bischoff, Henle, W T ildebrand, Muller, Wagner, Mandl, Gerber, Liebig, Carpenter, Todd 
and Bowman, as well as from various monographs which have appeared in the Cyclopaedias, Trans- 
actions of learned societies and journals. The large mass of references which it contains renders 
it a most valuable bibliographical record, and bears the highest testimony to the zeal and industry 
of the author." — British and Foreign Medical Review. 

" Many will be surprised to see a fifth edition of this admirable treatise so rapidly succeeding the 
fourth. But such has been the rapid progress of physiology within a short period that to make his 
work a fair reflection of the present state of the science, no less than an account of its extensive 
popularity, Dr. Dunglison has found it necessary to put forth a new edition with material modifica- 
tions and additions. To those who may be unacquainted with the work, we may say that, Dr. D. 
does not belong to the mechanical, chemical, or vital school exclusively ; but that, with a discri- 
minating hand he culls from each and all, making his treatise a very excellent and complete digest 
of the vast subject."— ^Western Journal of Medicine and Surgei'y. 



NEW REMEDIES, 
PHARMAOEUTICALLY AND THERAPEUTICALLY CONSIDERED, 

BY ROBLEY DUNGLISON, M.D., 
In One Volume, Octavo, over 600 pages, the Fourth Edition. 



Or, the Influence of Atmosphere and Locality, Change of Air and Climate, 

Seasons, Food, Clothing,, Bathing and Mineral Springs, Exercise, 

Sleep, Corporeal and Intellectual Pursuits, &c., &c, on 

Healthy Man: Constituting s 

ELEMENTS OF HYGIENE. 

BY ROBLEY DUNGLISON, M.D. 

A New Edition with many Modifications and Additions. In One Volume, 8vo. 
" We have just received the new edition of this learned work on the e Elements of Hygiene.' — 
Dr. Dunglison is one of the most industrious and voluminous authors of the day. How he finds 
time to amass una arrange the immense amount of matter contained in his various works, is almost 
above the comprehension of men possessing but ordinary talents and industry. Such labour de- 
serves immortality." — St. Louis Med. and Surg. Journal. 



A NEW EDITION OF 

THE MEDICAL STUPE \-T; 

OR AIDS TO THE STUDY OF MEDICINE. 

A REVISED AND MODIFIED EDITION, 

BY ROBLEY DUNGLISON, M.D.> 

In One neat 12mo, Volume, 



LEA & BLAN CHARD'S PUBLICATIONS. 17 

CHAPMAN'S WORKS ON THE PRACTICE OF MEDICINE. 
CHAPMAN ON FEVERS, ETC. 

LECTURES ON THE MORE IMPORTANT 

ERUPTIVE FEVERS. HAEMORRHAGES AND 

DROPSIES. AND ON GOUT AND RHEUMATISM. 

DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. 

By N. CHAPMAN, M.D., 

Professor of the Theory and Practice of Medicine, kc. &c. 

In one neat Octavo Volume. 
This volume contains Lectures on the following subjects: 

EXA.NTHEMATOUS FEVERS. 

Variola, or Small Pox : Inoculated Small Pox: Varicella, or Chicken Poj : Variolae Vaccinia?, or Vareinia, 
or Cow-pock : Varioloid Disease : Rubeola. Morbilii. or Measles : Scarlatina vei Febris Rubra — Scarlet Ft 

HEMORRHAGES. 

Haemoptysis. Spitting of Blood: Haemorrhag"ia Narium. or Haemorrhage from the Nose: Ha?matemesis. or 
Vomiting of Blood ; Haematuria. or Voiding of Bloody Urine : Haemorrhagia UteriUa. or Uterine Haemorrhage ) 
Haemorrhois or Haemorrhoids: Cutaneous Haemorrhage : Purpura Haemorrhacica. 

DROPSIES. 

Ascites; Encysted Dropsy: Hydrothorax: Hydrops Pericardii: Hydrocephalus Internus. aeute. subacute. 
and chronic : Anasarca : with a Disqu:sir.on on the Management of the wnc 

GOUT. RHEUMATISM, kc. ke. 
7iie name of Chapman stands deservedly high in the annals of American medical science. A teacher and a 
lecturer for nearly forty years, in the oldest and. we believe, the first medical school on this side of the Atlantic, 
the intimate friend and companion of Rush. Ruhn. Physick. Wistar. Wood;. a ea, and a host of others 

scarcely less renowned. Professor Chapman reflects upon the profession of this generation something of the 
genius and wisdom of that which has passed: he stands out the able and eloquent champion of the 
and principles of other times, when Culien's -first lines'' formed the rule of faith for all the Doctors in Me:, 
throughout Christendom. In him is embodied the experience of three score and ten. strengthened by reading, 
and enlightened by a familiar intercourse with many of the ablest medical men in the New aud Old World. 

*■ In con;- nust declare our belief that the name of Chapman will survive when that of many of his 

cotemporaries shall have been forgotten: when other generations shall tread the gTeat theatre of human 
affairs, and when other disco ..disclosed. shalUshed abrighter light upon the path of medic 

The various lectures which he has been publishing, containing, as they do. the docirines that he has so long 
aud so eloquently taught to large and adm re doubt not will be welcomed with delight by Ida nu- 

merous pupils throughout the Lnion.^ — New O'-ieans Medical Journal. 



CHAPMAN ON THORACIC VISCERA, ETC. 

LECTURES ON THE MORE IMPORTANT DISEASES 

OF THE 

THORACIC AND ABDOMINAL VISCERA, 

DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. 
By N. CHAPMAN, M.D. 

Professor of the Theory and Practice of Medicine. &c 

la one Volume, Octavo. 

WILLIAMS AND CLYMER D N THE RESPIRATORY ORGANS, ETC. 

A TREATISE ON THE 

DISEASES OF THE RESPIRATORY ORGANS, 

INCLUDING 

THE TRACHEA. LARYNX, LUNGS, AND PLEURA. 
By CHARLES J. B. WILLIAMS, M.D., 

Consulting Physician to the Hospital for Consumption and Diseases of the Chest; Author of 
r.clpies of Medicine." ie. kc. 

WITH NUMEROUS ADDITIONS AND NOTES. 
By MEREDITH CLYMER. M.D., 

Physician to the Philadelphia Hospital. 

In one neat Svo. Volume, with Cuts. 

This work recommends itself to the notice of the profession as containing a more particu- 
lar and detailed account of the affections of which it treats than perhaps any other volume 
before the public. 

■ The wood cats illustrating the physical examination of the chest, are admirably executed, and the whole 
mechanical execution of the work, does much credit 10 the publishers. This work is undoubtedly destined to 
take precedence of all others - ed on the " Respiratory Organs.* 7 and as a text book for leaehen ana 

students, no better in the present state of the science is to be expected "—yuc York Journal of Medisiru* 



18 LEA & BLANCHARD'S PUBLICATIONS. 

NOW READY, 

A NEW AND IMPROVED EDITION 

OF RAMSBOTHAM'S STANDARD WORK ON PARTURITION. 



THE PRINCIPLES AND PRACTICE OF 

OBSTETRIC MEDICINE AND SURGERY, 

IN REFERENCE TO £ j 

THE PROCESS OF PARTURITION. 

ILLUSTRATED BY 

One hundred and forty-eight Large Figures on 85 Lithographic Plates. 
By FRANCIS H. RAMSBOTHAM, M. D., &c. 

A NEW EDITION, FROM THE ENLARGED AND REVISED LONDON EDITION. 

In one large imperial octavo volume ; well bound. 

The present edition of this standard work will be found to contain numerous and important improvements 
over the last. Besides much additional matter, there are several more plates and wood-cuts, and those which 
were before used have been re-drawn. This book has long been known to the profession, by whom it has 
been most flatteringly received. The publishers take great pleasure in submitting the following testimony to 
lis value from Professor Hodge, of the Pennsylvania University. 

Philadelphia, August 6th, 1845. 
Gentlemen:— I have looked over the proofs of Ramsbotham on Human Parturition, with its important 
improvements, from the new London edition. 

This Work needs no commendation from me, receiving, as it does, the unanimous recommendation of the 
British periodical press, as the standard work on Midwifery ; " chaste in language, classical in composition, 
happy in point of arrangement, and abounding in most interesting illustrations."* 

To the American public, therefore, it is most valuable— from its intrinsic undoubted excellence, and as 
being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive through- 
out our country. 

There is, however, a portion of Obstetric Science to which sufficient attention, it appears to me, has not 
been paid. Through you, I have promised to the public a work on this subject, and although the continued 
occupation of my time and thoughts in the duties of a teacher and practitioner have as yet prevented the ful- 
filment of the promise, the day, I trust, is not distant, when, under the hope of being useful, I shall prepare 
an account of the Mechanism of Labour, illustrated by suitable engravings, which may be regarded as an 
addendum to the standard works of Ramsbotham, and our own Dewees. 

Very respectfully, yours, 

HUGH L. HODGE, M. D., 
Professor of Obstetrics, #c. $c.,in the University of Pennsylvania. 
Messrs. Lea & Blanchard. 



u This new edition of Dr. Ramsbotham's work forms one of the most complete and thoroughly useful treatises 
on Midwifery with which we are acquainted. It is not a mere reprint of the first edition; the entire work 
has undergone a careful revision, with additions. We have already given specimens of the work sufficient 
to justify our hearty recommendation of it as one of the best guides that the student or young practitioner can 
follow."— British and Foreign Medical Review, Jan., 1845. 

" The work of Dr. Ramsbotham may be described as a complete system of the principles and practice of 
Midwifery; and the author has been at very great pains, indeed, to present a just and useful view of the pre- 
sent state of obstetrical knowledge. The illustrations are numerous, well selected, and appropriate, and en- 
graved with great accuracy and ability. In short, we regard this work, between accurate descriptions and 
useful illustrations, as by far the most able work on the Principles and Practice of Midwifery that has ap- 
peared for a long time. Dr. Ramsbotham has contrived to infuse a larger proportion of common sense, and 
plain unpretending practical knowledge into this work, than is commonly found in works on this subject; 

* Northern Journal of Medicine for July 184-5. 



LEA & BLANCHARD'S PUBLICATIONS. 19 

RAXKSBOXHAIVE ON PAHTURITION— Continued. 

and as such we have great pleasure in recommending it to the attention of obstetrical practitioners."— Edin- 
burgh Medical and Surgical Journal. 

"This is one of the most beautiful works which have lately issued from the medical press; and is alike 
creditable to the talents of the author and the enterprise of the publisher. It is a good and thoroughly prac- 
tical treatise ; the different subjects are laid down in a clear and perspicuous form, and whatever is of import 
ance, is illustrated by first rate engravings. A. remarkable feature of this work, which ought to be mentioned, 
is its extraordinary cheapness. As a work conveying good, sound, practical precepts, and clearly demonstra- 
ting the doctrines of Obstetrical Science, we can confidently recommend it either to the student or practi- 
tioner." — Edinburgh Journal of Medical Science. 

"This work forms a very handsome volume. Dr. Ramsbotham has treated the subject in a manner worthy 
of the reputation he possesses, and has succeeded in forming a book of reference for practitioners, and a solid 
and easy guide for students. Looking at the contents of the volume, and its remarkably low price, we have 
no hesitation in saying that it has no parallel in the history of publishing."— Provincial Medical and Surgi- 
cal Journal. 

"It is the book of Midwifery for students ; clear, but not too minute in its details, and sound in its practi- 
cal instructions. It is so completely illustrated by plates (admirably chosen and executed,) that the student 
must be stupid indeed who does not understand the details of this branch of the science, so far at least as 
description can make them intelligible." — Dublin Journal of Medical Science. 

"Our chief object now is to state our decided opinion, that this work is by far the best that has appeared in 
this country for those who seek practical information upon Midwifery, conveyed in a clear and concise style. 
The value of the work, too, is strongly enhanced by the numerous and beautiful drawings, which are in the 
first style of excellence."— London Medical Journal. 

"We most earnestly recommend this work to the student who wishes to acquire knowledge, and to the 
practitioner who wishes to refresh his memory, as a most faithful picture of practical Midwifery ; and we can 
with justice say, that altogether it is one of the best books we have read on the subject of Obstetric Medi- 
cine."— Medico-Chirurgical Review. 

"All the organs concerned in the process of parturition, and every step of this process, in all its different 

forms, are illustrated with admirable plates When we call to mind the toil we underwent in 

acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which this 

work will afford him We recommend the student who desires to master this difficult subject with 

the least possible trouble, to possess himself at once of a copy of this work." — American Journal of the Me- 
dical Sciences. 

"It is intended expressly for students and junior practitioners in Midwifery ; it is, therefore, as it ought t*> 
be, elementary, and will not consequently, admit of an elaborate and extended review. Our chief object 
now is to state our decided opinion, that this work is by far the best that has appeared in this country, for 
those who seek practical information upon Midwifery, conveyed in a clear and concise style. The value of 
the work, too, is strongly enhanced by the numerous and beautiful drawings by Bagg, which are in the first 
style of excellence. Every point of practical importance is illustrated, that requires the aid of the engraver 
to fix it upon the mind, and to render it clear to the comprehension of the student."— London Medical 
Gazette. 

" We feel much pleasure in recommending to the notice of the profession one of the cheapest and most ele- 
gant productions of the medical press of the present day. The text is written in a clear, concise, and simple 
style. We offer our most sincere wishes that the undertaking may enjoy all the success which it so well 
merits."— Dublin Medical Press. 

" We strongly recommend the work of Dr. Ramsbotham to all our obstetrical readers, especially to thoae 
who are entering upon practice. It is not only one of the cheapest, but one of the most beautiful works in 
Midwifery."— British and Foreign Medical Review. 

" Among the many literary undertakings with which the Medical press at present teems, there are few that 
deserve a warmer recommendation at our hands than the work— we might almost say the obstetrical library, 
comprised in a single volume — which is now before us. Few works surpass Dr. Ramsbotham's in beauty and 
elegance of getting up, and in the abundant and excellent engravings with which it is illustrated. We hear, 
tily wish the volume the success which it merits, and we have no doubt that before long it will occupy a 
place in every medical library in the kingdom. The illustrations are admirable; they are the joint production 
of Bagg and Adlard, and comprise within the series the best obstetrical plates of our best obstetrical authors, 
ancient and modern. Many of the engravings are calculated to fix the eye as much by their excellence of 
execution, and their beauty as works of art, as by their fidelity to nature and anatomical accuracy." — The 
Lancet. 

" This is a work of unusual interest and importance to students and physicians. It is from the pen of Dr, 
Ramsbotham, consulting physician in obstetric cases of the London Hospital, and embodies in one volume 
the Principles and Practice of Obstetric Medicine and Surgery. The treatise is admirably written, and illus- 
trated by a great variety of engravings: Indeed every thing in the obstetric art, capable of being explained 
by engravings, is displayed to the eye in these admirably executed prints. A medical correspondent of the 
New York American, says, that the 'universal voice of the British journals accords in commending this 
work N to the profession, as one of the best elementary treatises in the language,' and we can only say, in add*,* 
tion, that the American publishers have, as far as we can judge from the execution of the plates in their edi> 
tion, done full justice to the original work. We sincerely hope that it may meet with entire success, and w§ 
cannot doubt that, when its merits are fully known* H will be found in every medical library i.n the couxiU^.-* 
—Saturday Evening Post, 



30 LEA & BLANCHARD'S PUBLICATIONS. 

Now Ready, 
CHEMISTRY FOR STUDENTS. 



ELEMENTARY CMISTRY, THEORETICAL AND PRACTICAL 

By GEORGE FOWNES, Ph. D., 

Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c. 

With Numerous Illustrations. Edited, with Additions, 
By ROBERT BRIDGES, M. D., 

Professor of General and Pharmaceutical Chemistry in the Philadelphia College 
of Pharmacy, &c, &c. 

In one large duodecimo volume, sheep or extra cloth. 

This is among the cheapest volumes on Chemistry yet presented to the pro- 
fession. The character of the work is such as should recommend it to all col- 
leges in want of a text-book as an introduction to the larger and more advanced 
systems, such as Graham's and others. The great advantage which it possesses 
over all the other elementary works on the same subject now before the public, 
is the perfect manner in which it is brought up to the day on every pointy em- 
bracing all the latest investigations and discoveries of importance, in a concise 
and simple manner, adapted to the time and comprehension of students com- 
mencing the science. It forms a royal 12mo. volume of 460 large pages, on small 
type, embellished with over one hundred and sixty wood engravings, which 
will be found peculiarly instructive as to the practical operations of the labora- 
tory, and the new and improved methods of experimenting. 

It has already been adopted as a Text-book by Professor Silliman of Yale Col- 
lege, and by othor Colleges in different parts of the country. 



Extract from a letter from Prof essor Millington^ of being omitted, and appears to us extremely well 

William and Mary College, Va. adapted as a text-book for the pupil attending a course 

of lectures on chemistry. Indeed we have no doubt 

"I have perused the book with much pleasure, and that k wm uhimately become the medical studenl > s 

find U a most admirable work ; and, to my mind, such favourhe man aal »-DuWin Medical Press. 

a one as is just now much needed in schools and col- « Having examined it with some attention, we feel 

leges. * * * All the books I have met with on che- lifiedtOTecommendittoouryoungerreaderS asan 

mistry are either too puerile or too erudite, and I con- , . , , . . ,. , . MM% ^ „u^™;„„i 

■ ' ' y ,,.',. admirable exposition of the present state of chemical 

fess Dr. Fownes'b^k seems to be the happ,e s t medium sci t j „„,, clearIy writte n, and displaying a 

I have seen, and adrmrably suited to fill up the hiatus." thorough praetical know1ed g e of jfe detailSi as well a3 

a profound acquaintance with its principles." — British 

. . and Foreign Medical Review. 

Extract from a letter from Professor W. E. A. Aiktn, of u Numerous and useful as are the works extant on 

the University of Maryland. ^ $ clence of chemistry, we are nevertheless pre- 

" The first cursory examination left me prepossessed pared to admit that the author of this publication has 

in its favour, and a subsequent more careful review made a valuable addition to them by offering the stu- 

has confirmed these first impressions. I shall certainly dent and those in general who desire to obtain informa- 

recommend it to my classes, and feel sure that they tion, an accurate compendium of the state of chemical 

will profit by using it during the session of lectures. science; which is, moreover, well illustrated by ap- 

« As a judicious compendium, I think Fownes' Che- propriate and neatly executed wood engravings. * 

mistry cannot fail to be highly useful to the class of After what we have stated of this work, our readers 

readers for whom it was designed." will not be surprised that it has our hearty commenda- 
tion, and that, in our opinion, it is calculated, and at a 
trifling expense, to spread the doctrines of the intricate 

" Mr. Fownes' work, although consisting of only a science which it so clearly explains."— Medico- Chi- 

single thick 12mo. volume, includes a notice of almost rurgical Revieio. 
every branch of the subject, nothing of any importance 



LEA & BLANCHARD'S PUBLICATIONS. 



21 



"This is an unpretending, but decidedly valuable 
treatise, on the elements of chemistry, theoretical and 
practical. Dr. Bridges has a perfect idea of what is 
needed, and the preparation of this excellent guide 
should have the countenance of all public instructors, 
and especially those of medical students."— Boston 
Med. 4* Surg. Journal. 

" This is a very excellent manual for the use of stu- 
dents and junior practitioners, being sufficiently full 
and complete on the elements of the science, without 
omitting any necessary information, or extending too 
far into detail. It is written in a clear and concise 
style, and illustrated by a sufficient number of well 
executed wood-cuts and diagrams. The Editor has 
executed his task in a creditable manner, and we have 
no doubt the work will prove entirely satisfactory, as 
an introduction to the science of which it treats." — N. 
Y. Journal of Med. <$• Surgery. 

* He has succeeded in comprising the matter of his 
work in 4G0 duodecimo pages, which, assuredly, is a 
recommendation of the volume as a text-book for stu- 
dents. In this respect it has advantages over any 
treatise which has yet been offered to American stu- 
dents. The difficulty in a text-book of chemistry is to 
treat the subject with sufficient fullness without going 
too much into detail. For students comparatively 
ignorant of chemical science, the larger systems are 
unprofitable companions in their attendance upon lec- 
tures. They need a work of a more elementary cha- 
racter, by which they may be inducted into the first 
principles of the science, and prepared for mastering 



its more abstruse subjects. Such a treatise is the one 
which we have now the pleasure of introducing to our 
readers ; no manual of chemistry with which we have 
met comes so near meeting the wants of the beginner. 
All the prominent truths of the science, up to the pre- 
sent time, will be found given in it with the utmost 
practicable brevity. The style is admirable for its 
conciseness and clearness. Many wood-cuts are 
supplied, by which processes are made intelligible* 
The author expresses Tegret, that he could not enter 
more largely into organic chemisny, but his details 
will be found to embrace the most important facts in 
that interesting branch of the science. We shall re- 
commend his manual to our class next winter." — The 
Western Journal of Medicine and Surgery. 

" We are presented with a work, not only compre- 
hensive as regards general principles, but full of prac- 
tical details of the working processes of the scientific 
laboratory ; and in addition, it contains numerous 
wood engravings, showing the most useful forms of 
apparatus, with their adjustments and methods of use. 

"The original work having been full and complete, 
as far as the limits of such a volume would permit, 
and on every point brought up to the date of its publi- 
cation (in September last,) the task of the editor has 
been to add any important matter which appeared 
since, and to correct such typographical errors as had 
escaped the author. That this task has been well 
and ably performed, the known zeal and competency 
of Dr. Bridges afford a sufficient guarantee." — Thi 
Medical Examiner. 



GRAHAES'S CHBMXSTKir. 



THE ELEMENTS OF GHEMISTRY, 

INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS. 

With Numerous Illustrations. 



BY THOMAS GRAHAM, F. R. S.L. and E. D. 

Professor of Chemistry in University College, London, &c. &c. 

WITH NOTES AND ADDITIONS, 

BY ROBERT BRIDGES, M.D., &c. &c. 

In One Vol. Octavo. 

The great advancement recently made in all branches of chemical investigation, ren- 
ders necessary an enlarged work which shall clearly elucidate the numerous discoveries, 
especially in the department connected with organic Chemistry and Physiology, in 
which such gigantic strides have been made during the last few years. The present 
treatise is considered by eminent judges to fulfil these indications, and to be pecu- 
liarly adapted to the necessities of the advanced medical student and practitioner. In 
adapting it to the wants of the American profession, the editor has endeavoured to render 
his portion of the work worthy the exalted reputation of the first chemist of England. 
It is already introduced in many of the Colleges, and has universal approbation. 

Though so recently published, it has been translated into German, by Dr. F. Julius 
Otto, the eminent professor at Brunswick, and has already passed to a second edition. 



LEA & BLANCHARD'S PUBLICATIONS. 



A NEW MEDICAL DICTIONARY. 

Ill one Volume, large 12mo., now ready, at a low price. 

A DICTIONARY OF 

THE TERMS USED IN MEDICINE 

AND 

THE COLLATERAL SCIENCES; 

By RICHARD D. HOBLYN, A.M., Oxon. 
FIEST AMERICAN, FROM THE SECOND LONDON EDITION. 

REVISED, WITH NUMEROUS ADDITIONS, 

BY ISAAC HAYS, M.D., 

EDITOR OF THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 

Believing that a work of this kind would be useful to the profession in 
this country, the publishers have issued an edition in a neat form for the 
office table, at a low price. Its object is to serve as an introduction to the 
larger and more elaborate Dictionaries, and to assist the student commenc- 
ing the study of Medicine, by presenting in a concise form an explanation 
of the terms most used in Medicine and the collateral sciences, by giving 
the etymology and definition in a manner as simple and clear as possible, 
without going into details ; and bringing up the work to the present time 
by including the numerous terms lately introduced. This design the author 
has so ably executed as to elicit the highest encomiums of the medical 
press, a few of the testimonies of which are subjoined. 

It has been edited with especial reference to the wants of the American 
practitioner, the native medicinal plants being introduced, with the for- 
mulae for the various officinal preparations ; and the whole being made to 
conform to the Pharmacopoeia of the United States. It is now ready in 
one neat royal duodecimo volume of four hundred pages in double co- 
lumns. 

Extract from a Letter from Professor Watts of the College of Physicians and Surgeons , N. York. 

u It is a valuable book for those more advanced in the profession, but especially for 
students of Medicine, and I shall take pleasure in recommending it to my class during 
the coming session." 

OPINIONS OF THE PRESS. 

" We hardly remember to have seen so much valuable matter condensed into 
such a small compass as this little volume presents. The first edition was pub- 
lished in 1835, and the present may be said to be almost re-written, introducing 
the most recent terms on each subject. The Etymology, Greek, Latin, &c, is 
carefully attended to, and the explanations are clear and precise. We cannot too 
strongly recommend this small and cheap volume to the library of every student and 
every practitioner." — Medico- Chirurgical Review. 

" We gave a very favourable account of this little book on its first appearance, 
and we have only to repeat the praise with increased emphasis. It is, for its size, 
decidedly the best book of the kind, and ought to be in the possession of every 
student. Its plan is sufficiently comprehensive, and it contains an immense mass 
of necessary information in a very small compass." — British and Foreign Medi- 
cal Review. 

" A work much wanted, and very ably executed." — London Medical Journal. 

" This compendious volume is well adapted for the use of students. It contains 
a complete glossary of the terms used in medicine — not only those in common 
use, but also the more recent and less familiar names introduced by modern wri- 
ters. The introduction of tabular views of different subjects is at once compre- 
hensive and satisfactory." — Medical Gazette. 

" Concise and ingenious." — Johnson's Medico-Chirur. Journal. 

"It is a very learned, pains-taking, complete, and useful work — a Dictionary 
absolutely necessary in a medical library." — Spectator. 



LEA & BLANCHARD'S PUBLICATIONS. 



XiATELT PUBMSHHD. 

A NEW EDITION OF 

OAAFSSOBM KTJMAW PHYSIOLOGY, 

REVISED AND MUCH IMPROVED. 

PRINCIPLES OF HUMAN PHYSIOLOGY, 

WITH THEIR CHIEF APPLICATIONS TO 

PATHOLOGY, HYGIENE & FORENSIC MEDICINE. 

By WILLIAM B. CARPENTER, M.D., F.R.S., &c. 

SECOND AMERICAN, FROM A NEW AND REVISED LONDON EDITION. 

WITH NOTES AND ADDITIONS, 

BY MEREDITH CLYMER, M.D., &c, 
With Two Hundred and Sixteen Wood-cut and other Illustrations. 

In one octavo volume, of about 650 closely and beautifully printed pages. 

The very rapid sale of a large impression of the first edition is an evidence of the merits of this 
valuable work, and that it has been duly appreciated by the profession of this country. The pub- 
lishers hope that the present edition will be found still more worthy of approbation, not only from 
the additions of the author and editor, but also from its superior execution and the abundance of 
its illustrations. No less than eighty-five wood-cuts and another lithographic plate will be found 
to have been added, affording the most material assistance to the student. 

" We have much satisfaction in declaring our opinion that this work is the best systematic treat- 
ise on physiology in our own language, and the best adapted for the student existing in any lan- 
guage." — Medico-Chirurgical Review. 



NOW READY. 

A NEW AND IMPROVED EDITION OF 

FEUCtJSSON'S OPERATIVE Sttaa$?, 

A SYSTEM OF PRACTICAL SURGERY. 
By WILLIAM FERGUSSON, F.R.S.E. 

Second American Edition, Revised and Improved. 

WITH TWO HUNDRED AND FIFTY-TWO ILLUSTRATIONS FROM DRAWINGS BY BAGG, ENGRAVED BY 
GILBERT, WITH NOTES AND ADDITIONAL ILLUSTRATIONS, 

BY GEORGE W. NORRIS, M.D., &c. 
In one beautiful octavo volume of six hundred and forty large pages. 

The publishers commend to the attention of the profession this new and improved edition of 
Fergusson's standard work, as combining cheapness and elegance, with a clear, sound and practical 
treatment of every subject in surgical science. Neither pains nor expense have been spared to 
make it worthy of the reputation which it has already acquired, and of which the rapid exhaustion 
of the first edition is sufficient evidence. It is extensively used as a text-book in many medical 
colleges throughout the country. 

The object and nature of this volume are thus described by the author : — " The present work 
has not been produced to compete with any already before the Profession; the arrangement, the 
manner in which the subjects have been treated, and the illustrations, are all different from any of 
the kind in the English language. It is not intended to be placed in comparison with the elemen- 
tary systems of Cooper, Burns, Liston, Symes, Lizars, and that excellent epitome of Mr. Druitt.— 
It may with more propriety be likened to the Operative Surgery of Sir C. Bell, and that of Mr. 
Averill, both excellent in their day, or the more modern production of Mr. Hargrave, and the 
Practical Surgery of Mr. Liston. There are subjects treated of in this volume, however, which 
none of these gentlemen have noticed ; and the author is sufficiently sanguine to entertain the idea 
that this work may in some degree assume that relative position in British Surgery, which the 
classical volumes of Velpeau and Malgaigne occupy on the Continent." 

"If we were to say that this volume by Mr. Fergusson, is one excellently adapted to the stu- 
dent, and the yet inexperienced practitioner of surgery, we should restrict unduly its range. It is 
of the kind which every medical man ought to have by him for ready reference, as a guide to the 
prompt treatment of many accidents and injuries, which whilst he hesitates, may be followed by 
incurable defects, and deformities of structure, if not by death itself. In drawing to a close our 
notice of Mr. Fergusson's Practical Surgery, we cannot refrain from again adverting to the nume-» 
rous and beautiful illustrations by wood-cuts, which contribute so admirably to elucidate the de- 
scriptions in the text. Dr. Norris has, as usual, acquitted himself judiciously in his office of 
annotator. His additions are strictly practical and to the point," — Bulletin of Medical Science, 



24 LEA & BLANOHARD'S PUBLICATIONS. 

XiATBLlT PUBLISHES, 

A NEW EDITION OF 

WILSON'S HUMAN ANATOMY, 

Much Improved. 

GENERAL AND SPECIAL. 
BX DKASMUS WILSON, BE.D., 

Lecturer on Anatomy, London. 
SECOND AMERICAN EDITION, EDITED BY 

PAUL B. GODDARD, A.M., M.D., 

Lecturer on Anatomy and Demonstrator in the University of "Pennsylvania, 8$c. 

WITH OVER TWO HUNDRED ILLUSTRATIONS, 
Beautifully Printed from the Second London Edition. 

IN ONE VERY NEAT OCTAVO VOLUME. 
From the Preface to the Second American Edition. 

c< The very rapid sale of the first edition of this work, is evidence of its appreciation by the pro- 
fession, and is most gratifying to the author and American editor. In preparing the present edition 
no pains have been spared to render it as complete a manual of Anatomy for the medical student as 
possible. A chapter on Histology has therefore been prefixed, and a considerable number of new- 
cuts added. Among the latter, are some very fine ones of the nerves which were almost wholly 
omitted from the original work. Great care has also been taken to have this edition correct, and 
the cuts carefully and beautifully worked, and it is confidently believed that it will give satisfaction, 
offering a further inducement to its general use as a Text-book in the various Colleges." 

" Mr. Wilson, before the publication of this work, was very favourably known to the profession 
by his treatise on Practical and Surgical Anatomy ; and, as this is the Second American Edition, 
from the second London Edition, since 1840, any special commendation of the high value of the 
present work, on our part, would be supererogatory. Besides the work has been translated at Ber- 
lin, and overtures were repeatedly made to the London publisher for its reproduction in France. — 
The work is, undoubtedly, a complete system of human anatomy, brought up to the present day. — 
The illustrations are certainly very beautiful, the originals having been expressly designed and exe- 
cuted for this work by the celebrated Bagg of London; and, in the American edition they have 
been copied in a masterly and spirited manner. As a text-book in the various colleges we would 
commend it in the highest terms." — New York Journal of Medicine. 



CHURCHIL,L'S_ MIDWIFERY. 
ON THE THEORY AND PRACTICE OF MIDWIFERY, 

BY FLEETWOOD CHURCHILL, M.D., M.R.I.A., 

PHYSICIAN TO THE WESTERN LYING-IN-HOSPITAL, ETC., ETC. 

WITH NOTES AND ADDITIONS 

BY ROBERT HUSTON, M.D., 
Professor in the Jefferson Medical College, &c, &c. 

And One Hundred and Sixteen Illustrations,. 

Engraved by Gilbert from Drawings by Bagg and others. 
In one volume, octavo. 
This work commends itself to the notice of the profession from the high reputation of the author 
and editor, and the number and beauty of its illustrations. Besides accurate directions for 
THE PRACTICE OF MIDWIFERY, 
a portion of the work is also devoted to 
THE PHYSIOLOGY AND PATHOLOGY 
connected with that essential branch of medical knowledge. 
" It is impossible to conceive a more useful or elegant manual : the letter-press contains all that 
the practical man can desire ; the illustrations are very numerous, well chosen, and of the most ele- 
gant description, and the work has been brought out at a moderate price." — Provincial Med. Jour. 
ff We expected a first rate production, and we have not been in the least disappointed. Although 
we have many, very many valuable works on tokology, were we reduced to the necessity of pos- 
sessing but one, and permitted to choose, we would unhesitatingly take Churchill. "-^-Western Med. 
and Surg. Journal. 

This work is printed,' illustrated and bound to match Carpenter's Physiology, 
Fer^usson's Surgery and Wilson's Anatomy, and the whole, with Watson's Prac- 
tice, Pereira's Materia Medica and Graham's Chemistry, are extensively used in 
the various colleges. 



LEA & BLANCHARD'S PUBLICATIONS. 25 

PEREIM'S MATERIA MEDICA. 

with near three hundred engravings on wood. 
a new edition now bbady. 

THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. 

COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPO- 
SITION, EFFECTS, AND USES OF MEDICINES. 

BY JONATHAN PEREIRA, M.D., F.R.S. and L. S. 

Member of the Society of Pharmacy of Paris; Examiner in Materia Medica and Pharmacy of the 

University of London; Lecturer on Materia Medica at the London Hospital, &c, &c. 

Second American, from the last London Edition, enlarged and improved. With Notes and Additions 

BY JOSEPH CARSON, M.D., 

In two volumes, octavo. 

Part I, contains the General Action and Classification of Medicines and the Mineral Materia Me- 
dica. Part II, the Vegetable and Animal Kingdoms, and including diagrams explanatory of the 
Processes of the Pharmacopoeias, a tabular view of the History of the Materia Medica, from the 
earliest times to the present day, and a very copious index. From the last London Edition, which 
has been thoroughly revised, with the Introduction of the Processes of the New Edinburgh Phar- 
macopoeia, and containing additional articles on Mental Remedies, Light, Heat, Cold, Electricity ? 
Magnetism, Exercise, Dietetics and Climate, and many additional Wood-cuts, Illustrative of Phar- 
maceutical Operations, Crystallography, Shape and Organization of the Feculas of Commerce, and 
the Natural History of the* Materia Medica. 

The object of the author has been to supply the Medical Student with a Class Book on Materia 
Medica, containing a faithful outline of this Department of Medicine, which should embrace a con- 
cise account of the most important discoveries in Natural History, Chemistry, Physiology, and The- 
rapeutics, in so far as they pertain to Pharmacology, and treat the subjects in the order of their 
natural historical relations. 

The opportunity has been embraced in passing this New Edition through the hands of the Editor, 
Dr. Carson, to make such additions as were required to the day, and to correct such errors as had 
passed the inspection of the Author and Editor of the first edition. It may now be considered as 
worthy the entire confidence of the Physician and Pharmaceutist as a standard work. 

This great Library or Cyclopedia of Materia Medica has been fully revised, the errors corrected, 
and numerous additions made by DR. JOSEPH CARSON, Professor of Materia Medica and Phar- 
macy in the "College of Pharmacy," and forms Two Volumes, octavo, of near 1600 large and 
closely printed pages. It may be fully relied upon as a permanent and standard work for the coun- 
try — embodying, as it does, full references to the U. S. Pharmacopoeia and an account of the Medi- 
cal Plants indigenous to the United States. 

" An Encyclopaedia of knowledge in that department of medical science — by the common con' 
sent of the profession the most elaborate and scientific Treatise on Materia Medica in our lan- 
guage." — Western Journal of Medicine and Surgery. 

" Upon looking over the American edition of the Materia Medica of Dr. Pereira, we have seen no 
reason to alter the very favourable opinion expressed in former numbers of this Journal. (See Am. 
Med. Journal, XXIV, 413, and N. S., I. 192.) We are glad to perceive that it has been repub- 
lished here without curtailment. Independently of the injustice done to an author by putting forth 
an abbreviated edition of his works, without his superintendence or consent, such a course would 
in the present instance have been unjust also to the public, as one of the chief recommendations 
of Dr. Pereira's treatise is its almost encyclopedic copiousness. We turn to its pages with 
the expectation of finding information upon all points of Materia Medica, and would have good 
reason to complain were this expectation disappointed by the scissors of an American Editor. 
Indeed, the main defect of the work, in relation to American practitioners, was the want of 
sufficient notices of the medicines and preparations peculiar to this country. In the edition 
before us this defect has been supplied by the Editor, Dr. Joseph Carson, who was, in a high 
degree qualified for the task, and, so far as we are able to judge from a very partial perusal, has 
executed it with judgment and fidelity. The nomenclature and preparations of our national 
standard have been introduced when wanting in the English edition, and many of our medical 
plants, either briefly noticed or altogether omitted by Dr. Pereira, because unknown in Europe, 
have been sufficiently described. We must repeat the expression of our opinion that the work will 
be found an invaluable storehouse of information for the physician and medical teacher, and con- 
gratulate the profession of this country that it is now placed within their reach." — Am. Med.Journ. 

" To say that these volumes on Materia Medica and Therapeutics, by Dr. Pereira, are comprehen- 
sive, learned and practical, and adapted to the requirements of the practitioner, the advanced stu- 
dent, as well as the apothecary, expresses the opinion, we will venture to assert, of nearly every 
judge of the subject, but fails to convey to those who are not acquainted with the work, a definite 
idea of its really distinctive traits, according to our general usage, we shall, therefore, proceed to 
place these before our readers, so that they may know what it is, and why we praise. Valuable 
and various as are the contents of the volumes of Dr. Pereira, we Jiave no hesitation in assert- 
ing, despite the adverse cant in some quarters on the subject of the American additions to English 
works, that the value of the present edition is enhanced by the appropriate contributions of 
Dr. Carson, who has introduced succinct histories of the most important indigenous medicines of 
the United States Pharmacopoeia." — Select Med. Library, 



86 LEA & BLANCHARD'S PUBLICATIONS. 

THE SURGICAL WORKSJF SIR ASTLEY COOPER, 

LEA & BLANCHARD have now completed the last volume of the illustrated works of Sir Astley Cooper. 
They form an elegant series; the works on Hernia, the Testis, the Thymus Gland and the Breast, being print- 
ed, illustrated and bound to match, in imperial octavo with numerous LITHOGRAPHIC PLATES, while the 
Treatise on Dislocations is in a neat medium octavo form, with NUMEROUS WOOD-CUTS similar to the 
last London Edition. 



COOPER ON THE 

ANATOMY AND DISEASES OF THE BREAST, &c. 



JUST PUBLISHED. 



This large and beautiful volume contains THE ANATOMY OF THE BREAST; 

THE COMPARATIVE ANATOMY OF THE MAMMARY GLANDS; 

ILLUSTRATIONS OF THE DISEASES OF THE BREAST; 

And Twenty-five Miscellaneous Surgical Papers, now first published in a collected form, 

By SIR ASTLEY COOPER, Bart., F.R.S.,&c. 

The whole in one large imperial octavo volume, illustrated with two hundred and fifty -two figures on 
thirty six Lithographic Plates ; well and strongly bound. 

SIR ASTLEY COOPER ON HERNIA, 

With One Hundred and Thirty Figures in Lithography* 

THE ANATOMY AND SMGAL TREATMENT OF 

ABDOMINAL HI1NIA. 

By Sir ASTLEY COOPER, Bart. 
Edited by C. Aston Key, Surgeon to Guy's Hospital, &c. 

This important work of Sir Astley is printed from the authorized second edition, published in London, in 
large super-royal folio, and edited by his nephew, Professor Key. It contains all the Plates and all the Let- 
terpress—there areno omissions, interpolations, or modifications— it is the complete work in 

One Large Imperial Octavo Volume. 
WITH OVER 110 FIGURES ON 26 PLATES, AND OVER 400 LARGE PAGES OF LETTERPRESS. 

The correctness of the Plates is guaranteed by a revision and close examination under the eye of a distin- 
guished Surgeon of this city. 

ANOTHER VOLUME OF THE SERIES CONTAINS HIS TREATISE 

ON THE STRUCTURE AND DISEASES OF THE TESTIS. 

Illustrated by 120 Figures. From the Second London Edition. 
By BRANSBY B. COOPER, Esq. 

AND ALSO 

ON THE ANATOMY OF THE THYMUS GLAND. 

Illustrated by 57 Figures. 

The two works together in one beautiful imperial octavo volume, illustrated with twenty-nine plates in 
the best style of lithography, and printed and bound to match. 



COOPER ON FRACTURES AND DISLOCATIONS, 

WITH NUMEROUS WOOD-CUTS. 
A. TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. By SIR ASTLEY COOPER, 

Bart., F. R. S., Sergeant Surgeon to the King, &c. 
A new edition much enlarged ; edited by BRANSBY COOPER, F.R.S., Sui^eon to Guy's Hospital, with ad- 
ditional Observations from Professor John C. Warren, of Boston. With numerous engravings on wood, 
after designs by Bagg, a memoir and a splendid portrait of Sir Astley. In one oclavo^volume. 
The peculiar value of this, as of all Sir Astley Cooper's works, consists in its eminently practical character. 
His nephew, Bransby B. Cooper, from his own experience, has added a number of cases. Besides this, Sir 
Astley left behind him very considerable additions in MS. for the express purpose of being introduced into this 
edition. The volume is embellished with ONE HUNDRED AND THIRTY-THREE WOOD-CUTS, and 
-contains the history of no less than three hundred and sixty-one cases, thus embodying the records of a life of 
practice of the Author and his various editors. There are also additional Observations from notes furnished 
by John & Warren, M.D., the Professor of Anatomy and Surgery in Harvard University. 

" After the fiat of the profession, it would be absurd in us to eulogize Sir Astley Cooper's work on Fractures 
and Dislocations. It is a national one^ .and will probably subsist as long as English surgery. "— Medico- Chirur- 
gical Review* 



LEA & BLANCHARD'S PUBLICATIONS. 27 

LATELY PUBLISHED. 

MEIGS* TRANSLATION 

N OF 

COLOMBAT DE L'ISERE GN THE DISEASES OF FEMALES. 

A TREATISE ON THE DISEASES OF FEMALES, 

AND ON 

THE SPECIAL HYGIENE OF THEIR SEX. 

WITH NUMEROUS WOOD-CUTS. 
BY COLOMBAT DE L'ISfiRE, M.D., 

Chevalier of the Legion of Honor; late Surgeon to the Hospital of the Rue de Valois, devoted to the Diseasfi of 

Females, #c, Sfc, 

TRANSLATED, WITH MANY NOTES AND ADDITIONS, 
By C. D. MEIGS, M.D., 

Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, <$•<;., SfC. 

In One Large Volume, 8vo. 
cc We are satisfied it is destined to take the front rank in this department of medical science; it is 
beyond all comparison, the most learned Treatise on the Diseases of Females that has ever been 
written, there being more than one thousand distinct authorities quoted and collected by the inde- 
fatigable author. It is in fact a complete exposition of the opinions and practical methods of all 
the celebrated practitioners of ancient and modern times. The Editor and Translator has per- 
formed his part in a manner hardly to be surpassed. The translation is faithful to the original, and 
yet elegant. More than one hundred pages of original matter have been incorporated in the text, 
constituting a seventh part of the whole volume." — New York Journal of Medicine, 



ASHWELL ON THE DISEASES OF FEMALES. 

A PRACTICAL TREATISE ON THE 

DISEASES PECULIAR TO WOMEN, 

ILLUSTRATED BY CASES DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. 
By SAMUEL ASHWELL, M.D., 

Member of the Royal College of Physicians; Obstetric Physician and Lecturer to Guy's Hospital, &c. 

WITH ADDITIONS, 
By PAUL BECK GODDARD, M.D. 
P The whole complete in one Large Octavo Volume. 

" The most able, and certainly the most standard and practical work on female diseases that we 
have yet seen." — Medico- Chirurgical Review. 



A NEW EDITION OF CHURCHILL ON FEMALES, 
THE DISEASES OF FEMALES. 

INCLUDING THOSE OF * 

By FLEETWOOD CHURCHILL, M.D., 

Author of "Theory and Practice of Midwifery,' 1 &c, &c. 
THIRD AMERICAN, FROM THE SECOND LONDON EDITION. 

With Illustrations. Edited with Notes, 

By ROBERT M. HUSTON, M.D., &c, &c. 
In One Volume, 8vo. 

" In complying with the demand of the profession in this country for a third edition, the Editor 
has much pleasure in the opportunity thus afforded of presenting the work in its more perfect form. 
All the additional references and illustrations contained in the English copy, are retained in this." 



TAITLOR'S JURISPRUDENCE. 

MEDICAL JURISPRUDENCE, 

BY ALFRED S. TAYLOR. 

Lecturer on Medical Jurisprudence and Chemistry at Guy's Hospital. 

With numerous Notes and Additions, and References to American Law. 

BY R. E. GRIFFITH, M.D. 
In one volume, octavo, sheep. Also, done up in neat law sheep. 



28 LEA & BLANCHARD'S PUBLICATIONS. 

CONPIB ON CHILDREN. 

A PRACTICAL TREATISE 

ON 

THE DISEASES OF CHILDREN, 

BY D. FRANCIS CONDIE, M. D. 

Fellow of the College of Physicians; Member of the American Philosophical Society, &c. &c. 

In one volume, octavo. 

§£r The Publishers would particularly call the attention of the Profession to an examination 

of this work. 
" Dr. Condie, from the very great labour which he has evidently bestowed upon this book, is entitled 
to our respect as an indefatigable and conscientious student; but if we consider the results of his 
labour, we cannot but admit his claim to a place in the very first rank of eminent writers on the 
practice of medicine. Regarding his treatise as a whole, it is more complete and accurate in its 
descriptions, while it is more copious and more judicious in its therapeutical precepts than any of 
its predecessors, and we feel persuaded that the American medical profession will very soon regard 
it, not only as a very good, but as the very best < Practical Treatise on the Diseases of Children.' J? 
< — Am, Med. Journal. 

THOMSON ON THE SICK ROOM. 



THE 1B1ESTIG 1AIABEMENT OF THE SICK KOBM, 

NECESSARY, IN AID OF MEDICAL TREATMENT, FOR THE 
CURE OF DISEASES. 

BY A. T. THOMSON, M.D., &c. &c. 

First American, from tlie Second London Edition, 

Edited by R. E. GRIFFITH, M. D. 
In one royal 12mo. volume, extra cloth, with cuts. 

" There is no interference with the duties of the medical attendant, but sound, sensible, and 
clear advice what to do, and how to act, so as to meet unforeseen emergencies, and co-operate with 
professional skill." — Literary Gazette. 

MILLER'S PRINCIPLES OF SURGBB.'Sr. 

THE PRINCIPLES OF SURGERY, 

By JAMES MILLER, F.R.S.E., F.R.C.S.E., 

Professor of Surgery in the University of Edinburgh, &c. 

In one neat 8vo. volume. 
To match in size with Fergusson's Operative Surgery. 

" No one can peruse this work without the conviction that he has been addressed by an accom- 
plished surgeon, endowed with no mean literary skill or doubtful good sense, and who knows how 
to grace or illumine his subjects with the later lights of our rapidly advancing physiology. The 
book deserves a strong recommendation, and must secure itself a general perusal." — Medical Times, 

WILLIAMS' PATHOLOGY. 

PRINCIPLES OF MEDICINE, 

COMPRISING 

GENERAL PATHOLOGY AND THERAPEUTICS, and a general view of ETIOLOGY, 

NOSOLOGY, SEMEIOLOGY, DIAGNOSIS AND PROGNOSIS. 

BY CHARLE6 J. B. WILLIAMS, M.D., F. K. S., 

Fellow of the Royal College of Physicians, etc. 1 

WITH ADDITIONS AND NOTES 
BY MEREDITH CLYMER, M. D. 

MMMf, Lecturer on the Institutes of Medicine, &c. &c. 

In one volume, 8vo. 

ALISON'S PAT HOLOGY. 

OUTLINES BF PATHOLOSY AND PRACTICE QF MEDICINE. 

BY WILLIAM PULTENEY ALISON, M. D., 

Professor of the Practice of Medicine in the University of Edinburgh, &c. &c. 

In Three Parts— -Part I. — Preliminary Observations — Part II. — Inflammatory and Febrile Diseases* 

and heart III. — Chronic or Non-Febrile Diseases. In one volume, octavo. 



WORKS ON THE VARIOUS DEPARTMENTS OF MEDICINE 

AND SOiiNOE 

PUBLISHED BY LEA & BLANCHARD. 



ANATOMICAL ATLAS. One vol. 8vo. 
See Advertisement. 

AMERICAN JOURNAL OF THE MEDI- 
CAL SCIENCES. See Advertisement. 

ANDRAL ON THE BLOOD. Pathologi- 
cal Hematology ; An Essay on the Blood in 
Disease. Translated by J. F. Meigs and Alfred 
Stille. In one octavo volume, cloth. 

ARNOTT'S PHYSICS. The Elements of 
Physics, in Plain, or Non-Technical Language. 
A New Edition. Edited by Isaac Hays. One 
octavo volume, sheep. With numerous cuts. 

ABERCROMBIE .ON THE BRAIN. Pa- 
thological and Practical Researches on the 
Diseases of the Brain and Spinal Cord. A 
New Edition. In one volume, 8vo. 

ABERCROMBIE ON THE STOMACH. 
Pathological and Practical Researches on Dis- 
eases of the Stomach, Intestinal Canal, &c. 
The Fourth Edition. In one vol. 8vo. 

ALISON'S PATHOLOGY. One vol. 8vo. 
See Advertisement. 

ASHWELL ON FEMALES. One vol. 
8vo. See Advertisement. 

BERZELIUS ON KIDNEYS, &c. The 
Kidneys and Urine. Translated by J. C. 
Booth and M. H. Bove. One 8vo. vol. cloth. 

BARTLETT ON FEVERS OF THE U. S. 
The History, Diagnosis, and Treatment of 
Typhus and Typhoid Fevers; and on Bilious, 
Remittent and Yellow Fever. In one neat 
octavo volume, extra cloth. 

BARTLETTS PHILOSOPHY OF MEDI- 
CINE. Essay on the Philosophy of Medical 
Science. In Two Parts. One neat octavo 
volume, extra cloth. 

BILLING : S PRINCIPLES OF MEDI- 
CINE. The First Principles of Medicine. 
From the Fourth London Edition. In one 
octavo volume, cloth. 

BRIGHAM ON MENTAL EXCITE- 
MENT. The Influence of Mental Cultiva- 
tion, and Mental Excitement on Health. In 
one 12mo. volume, cloth. 

BRODIE ON URINARY ORGANS. Lee- 
tures on the Diseases of the Urinary Organs. 
In one small octavo volume, cloth. 

BRODIE ON THE JOINTS. Pathological 
and Surgical Observations on the Diseases of 
the Joints. In one small octavo volume cloth. 

BRODIE'S LECTURES ON PROMINENT 
POINTS OF SURGERY. One volume, 8vo. 

BUCKLAND'S GEOLOGY. Geology and 
Mineralogy with Reference to Natural Theo- 
logy. A Bridgewater Treatise. In two vols. 
8vo. With numerous Maps, Plates, and Cuts. 

BREWSTER : S OPTICS. A Treatise on 
Optics. With numerous Wood Cuts. One vol- 
ume, 12mo. half bound. 

CHELIUS ; SYSTEM OF SURGERY. 
Edited by South and Norris. Now publishing 
in Par*s, to make 2 volumes octavo. 

j COLOMBAT DE LTS&RE ON FE- 
MALES. A Treatise on the Diseases of Fe- 
males, and on the Special Hygiene of their Sex. 
Translated by CD. Meigs. In one large 8vo. 
vol. sheep. W T ith Cuts. See Advertisement. 

CHAPMAN ON VISCERA, &c. &c. 1 

vol. 8vo. See Advertisement, 



CHAPMAN ON FEVERS, &c. \ voL 

8vo. See Advertisement. 

CARPENTER'S HUMAN PHYSIOLOGY. 
See Advertisement. 

CARPENTER'S VEGETABLE PHYSIO- 
LOGY. Popular Vegetable Physiology. With 
Numerous Illustrations. In one neat 12mo, 
volume, extra cloth. 

COOPER'S (Sir Astley.) GREAT WORK 
ON HERNIA. See Advertisement, 

COOPER ; (Sir Asteey.) ON THE TES- 
TIS, &c. See Advertisement. 

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j^toladelphia, October 9 1845. * 



fete- 



